Basic Information
| Provider Information | |||||||||
| NPI: | 1215217286 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POTAKIS | ||||||||
| FirstName: | ISMENE | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 675 N SAINT CLAIR ST STE 14-200 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606115966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126957542 | ||||||||
| FaxNumber: | 1269554623 | ||||||||
| Practice Location | |||||||||
| Address1: | 675 N SAINT CLAIR ST STE 14-200 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606115966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1269575423 | ||||||||
| FaxNumber: | 3126955462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2011 | ||||||||
| LastUpdateDate: | 08/24/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 085004104 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.