Basic Information
| Provider Information | |||||||||
| NPI: | 1790189561 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAMBLE | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 680 N LAKE SHORE DR | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606114546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126956868 | ||||||||
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| Practice Location | |||||||||
| Address1: | 680 N LAKE SHORE DR | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126956868 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2014 | ||||||||
| LastUpdateDate: | 06/21/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 085.007056 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 8525NU | 01 | TX | BCBS | OTHER | 342568802 | 05 | TX | MEDICAID |