Provider Demographics
NPI:1790193423
Name:MARTIN, DEANNA B S (PA-C)
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:B S
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DEANNA
Other - Middle Name:BARBARA
Other - Last Name:SHIPPEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:680 N LAKE SHORE DR
Mailing Address - Street 2:SUITE #1000
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-4546
Mailing Address - Country:US
Mailing Address - Phone:312-695-0665
Mailing Address - Fax:
Practice Address - Street 1:251 E HURON
Practice Address - Street 2:FEINBERG 16-738
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611
Practice Address - Country:US
Practice Address - Phone:312-926-5924
Practice Address - Fax:312-926-6134
Is Sole Proprietor?:No
Enumeration Date:2014-07-25
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085005106363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant