Provider Demographics
NPI:1942223334
Name:MICCI, SANDRA JEAN (PA-C)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:JEAN
Last Name:MICCI
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 1:101 HELM RD
Mailing Address - Street 2:
Mailing Address - City:BARRINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60010-7645
Mailing Address - Country:US
Mailing Address - Phone:847-551-3518
Mailing Address - Fax:312-572-4559
Practice Address - Street 1:1901 W HARRISON ST
Practice Address - Street 2:JOHN H STROGER HOSPITAL/ CORE CENTER
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3714
Practice Address - Country:US
Practice Address - Phone:312-572-4570
Practice Address - Fax:312-572-4559
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-000483363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILQ72026Medicare UPIN