Provider Demographics
NPI:1891450565
Name:BORMANN, RILEY MAE (PA-C)
Entity Type:Individual
Prefix:
First Name:RILEY
Middle Name:MAE
Last Name:BORMANN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:RILEY
Other - Middle Name:MAE
Other - Last Name:FLAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RILEY MAE FLAKE, PA
Mailing Address - Street 1:9977 WOODS DR # 100
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-1057
Mailing Address - Country:US
Mailing Address - Phone:243-642-2732
Mailing Address - Fax:
Practice Address - Street 1:9977 WOODS DR # 100
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-1057
Practice Address - Country:US
Practice Address - Phone:243-642-2732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-07
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
IL085009920363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant