Provider Demographics
NPI:1962026997
Name:SHANE, RACHEL (PA-C)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:
Last Name:SHANE
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 1:676 N SAINT CLAIR ST STE 415
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3133
Mailing Address - Country:US
Mailing Address - Phone:312-926-3627
Mailing Address - Fax:312-694-4103
Practice Address - Street 1:676 N SAINT CLAIR ST STE 415
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3133
Practice Address - Country:US
Practice Address - Phone:312-926-3627
Practice Address - Fax:312-694-4103
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-05
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL085009026363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program