Basic Information
| Provider Information | |||||||||
| NPI: | 1174757983 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TALISSE | ||||||||
| FirstName: | CAROL | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5019 N MOZART ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606253615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732933223 | ||||||||
| FaxNumber: | 7732934197 | ||||||||
| Practice Location | |||||||||
| Address1: | 5115 N FRANCISCO AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606253611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732712225 | ||||||||
| FaxNumber: | 7732711145 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2009 | ||||||||
| LastUpdateDate: | 10/30/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 085-003354 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 085003354 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 085-003354 | 01 | IL | LICENSE | OTHER |