Provider Demographics
NPI:1801379383
Name:O' BRYAN, SOPHIA HOPE KANNENBERG (PA-C)
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:HOPE KANNENBERG
Last Name:O' BRYAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 E ROLLINS RD
Mailing Address - Street 2:
Mailing Address - City:ROUND LAKE BEACH
Mailing Address - State:IL
Mailing Address - Zip Code:60073-2228
Mailing Address - Country:US
Mailing Address - Phone:847-324-3976
Mailing Address - Fax:847-929-1154
Practice Address - Street 1:720 FLORSHEIM DR
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-3757
Practice Address - Country:US
Practice Address - Phone:847-247-4000
Practice Address - Fax:847-234-2090
Is Sole Proprietor?:No
Enumeration Date:2018-09-11
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-006740363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant