Basic Information
| Provider Information | |||||||||
| NPI: | 1407468093 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANDERS | ||||||||
| FirstName: | ELLEN | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 675 N SAINT CLAIR ST STE 19-100 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606115969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 3126950063 | ||||||||
| Practice Location | |||||||||
| Address1: | 675 N SAINT CLAIR ST STE 19-100 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606115969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3125724500 | ||||||||
| FaxNumber: | 3126950063 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2020 | ||||||||
| LastUpdateDate: | 03/31/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 085007656 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.