Provider Demographics
NPI:1952666992
Name:COTTRELL, THOMAS LC III (PA-C)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:LC
Last Name:COTTRELL
Suffix:III
Gender:M
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 1:2 W TALCOTT RD STE 16
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-5558
Mailing Address - Country:US
Mailing Address - Phone:847-318-5500
Mailing Address - Fax:847-318-1567
Practice Address - Street 1:2 WEST TALCOTT RD SUITE 16
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-5558
Practice Address - Country:US
Practice Address - Phone:847-318-5500
Practice Address - Fax:847-318-1567
Is Sole Proprietor?:No
Enumeration Date:2012-07-05
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004334363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical