Provider Demographics
NPI:1952313207
Name:CHARLES FIELDS, LISA ANN (PHD, PA-C)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:ANN
Last Name:CHARLES FIELDS
Suffix:
Gender:F
Credentials:PHD, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1809 SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:NORTH CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60064-2235
Mailing Address - Country:US
Mailing Address - Phone:847-785-0611
Mailing Address - Fax:847-785-0612
Practice Address - Street 1:1809 SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:NORTH CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60064-2235
Practice Address - Country:US
Practice Address - Phone:847-785-0611
Practice Address - Fax:847-785-0612
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2017-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.001395363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085-001395Medicaid
ILP42388Medicare UPIN