Provider Demographics
NPI:1215217286
Name:POTAKIS, ISMENE (PA-C)
Entity type:Individual
Prefix:
First Name:ISMENE
Middle Name:
Last Name:POTAKIS
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 1:675 N SAINT CLAIR ST STE 14-200
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-5966
Mailing Address - Country:US
Mailing Address - Phone:312-695-7542
Mailing Address - Fax:126-955-4623
Practice Address - Street 1:675 N SAINT CLAIR ST STE 14-200
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-5966
Practice Address - Country:US
Practice Address - Phone:126-957-5423
Practice Address - Fax:312-695-5462
Is Sole Proprietor?:No
Enumeration Date:2011-08-23
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004104363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant