Provider Demographics
NPI:1962506410
Name:WITT, VALERIE M (PA)
Entity Type:Individual
Prefix:
First Name:VALERIE
Middle Name:M
Last Name:WITT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:VALERIE
Other - Middle Name:M
Other - Last Name:STARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:188 W INDUSTRIAL DR
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-1623
Mailing Address - Country:US
Mailing Address - Phone:630-410-9888
Mailing Address - Fax:630-941-8194
Practice Address - Street 1:188 W INDUSTRIAL DR
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-1623
Practice Address - Country:US
Practice Address - Phone:630-410-9888
Practice Address - Fax:630-941-8194
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002800363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCE9335OtherRR GROUP NUMBER
IL08500280OtherLICENSE
ILP00345216OtherRR MEDICARE NUMBER
IL214881Medicare Oscar/Certification
IL214881094Medicare PIN