Basic Information
Provider Information | |||||||||
NPI: | 1104176262 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | OKIGAWA | ||||||||
FirstName: | ASHLEY | ||||||||
MiddleName: | L. | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHYSICIAN ASSISTANT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LUSTGARTEN | ||||||||
OtherFirstName: | ASHLEY | ||||||||
OtherMiddleName: | L. | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | P. A. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1710 N RANDALL RD STE 140 | ||||||||
Address2: |   | ||||||||
City: | ELGIN | ||||||||
State: | IL | ||||||||
PostalCode: | 601239401 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2242931170 | ||||||||
FaxNumber: | 8472890960 | ||||||||
Practice Location | |||||||||
Address1: | 1710 N RANDALL RD STE 140 | ||||||||
Address2: |   | ||||||||
City: | ELGIN | ||||||||
State: | IL | ||||||||
PostalCode: | 601239401 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2242931170 | ||||||||
FaxNumber: | 8472890960 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/17/2012 | ||||||||
LastUpdateDate: | 09/16/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/16/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X |   | IL | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 085004508 | IL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 085004508 | 05 | IL |   | MEDICAID |