Provider Demographics
NPI:1740999093
Name:BAUERS, ANNALISE (PA-C)
Entity type:Individual
Prefix:
First Name:ANNALISE
Middle Name:
Last Name:BAUERS
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 1:350 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:IL
Mailing Address - Zip Code:60101-4911
Mailing Address - Country:US
Mailing Address - Phone:630-948-3989
Mailing Address - Fax:
Practice Address - Street 1:350 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:IL
Practice Address - Zip Code:60101-4911
Practice Address - Country:US
Practice Address - Phone:630-948-3989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-15
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0008716207Q00000X
IL085.009330363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDC0008716OtherMEDICAL LICENSE
IL085.009330OtherPROFESSIONAL LICENSE