Basic Information
| Provider Information | |||||||||
| NPI: | 1366994378 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OIE | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 472 ROUTE 47 | ||||||||
| Address2: | |||||||||
| City: | SUGAR GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605548107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6304666000 | ||||||||
| FaxNumber: | 6304666001 | ||||||||
| Practice Location | |||||||||
| Address1: | 472 ROUTE 47 | ||||||||
| Address2: | |||||||||
| City: | SUGAR GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60554 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6304666000 | ||||||||
| FaxNumber: | 6304666001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2016 | ||||||||
| LastUpdateDate: | 07/20/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 209014750 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 209014750 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 206147 | 01 | IL | MEDICARE PTAN GROUP | OTHER | F400353450 | 01 | IL | MEDICARE PTAN INDIVIDUAL | OTHER |