Basic Information
| Provider Information | |||||||||
| NPI: | 1144452327 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARITOTE | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2791 STOCKBERRY LN | ||||||||
| Address2: | |||||||||
| City: | WEST CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601856197 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302697231 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1325 N HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605061449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6308592222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2009 | ||||||||
| LastUpdateDate: | 12/13/2012 | ||||||||
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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 | 363A00000X | 085003479 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 085003479 | 01 | IL | STATE LICENSE NUMBER | OTHER |