Provider Demographics
NPI:1255950242
Name:TAACA, TRICIA MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:TRICIA
Middle Name:MARIE
Last Name:TAACA
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 1:415 DEVON LN
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-1108
Mailing Address - Country:US
Mailing Address - Phone:630-207-7985
Mailing Address - Fax:
Practice Address - Street 1:1499 LAKEWOOD DR STE A
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450-1791
Practice Address - Country:US
Practice Address - Phone:815-941-5160
Practice Address - Fax:815-941-5165
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-10
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL085.007865363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program