Provider Demographics
NPI:1336450048
Name:GILLESPIE, ANGELA (PA-C)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:GILLESPIE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:901 MCCLINTOCK DRIVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-0872
Mailing Address - Country:US
Mailing Address - Phone:888-220-6432
Mailing Address - Fax:630-654-4253
Practice Address - Street 1:901 MCCLINTOCK DRIVE
Practice Address - Street 2:SUITE 202
Practice Address - City:BURR RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60527-0872
Practice Address - Country:US
Practice Address - Phone:888-220-6432
Practice Address - Fax:630-654-4253
Is Sole Proprietor?:No
Enumeration Date:2010-06-28
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003762363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400166871Medicare PIN
ILF400166874Medicare PIN
ILF400138653Medicare PIN
ILF400166872Medicare PIN