Basic Information
| Provider Information | |||||||||
| NPI: | 1558734889 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SPERA | ||||||||
| FirstName: | TAYLOR | ||||||||
| MiddleName: | P. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | SPERA | ||||||||
| OtherFirstName: | TAYLOR | ||||||||
| OtherMiddleName: | P. | ||||||||
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| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4853 SOLUTIONS CTR | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606774008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604078000 | ||||||||
| FaxNumber: | 2604078004 | ||||||||
| Practice Location | |||||||||
| Address1: | 395 WESTFIELD RD | ||||||||
| Address2: | |||||||||
| City: | NOBLESVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460601425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177767199 | ||||||||
| FaxNumber: | 3177767921 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2015 | ||||||||
| LastUpdateDate: | 09/07/2016 | ||||||||
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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 | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 000000972951 | 01 | BCBS | OTHER |