Basic Information
| Provider Information | |||||||||
| NPI: | 1639321482 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHARTON | ||||||||
| FirstName: | STACIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 329 REMINGTON BLVD | ||||||||
| Address2: | UNIT 205 | ||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604405827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302261130 | ||||||||
| FaxNumber: | 3602261134 | ||||||||
| Practice Location | |||||||||
| Address1: | 431 WEST LIBERTY STREET | ||||||||
| Address2: | |||||||||
| City: | WAUCONDA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475262151 | ||||||||
| FaxNumber: | 8156784184 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2008 | ||||||||
| LastUpdateDate: | 12/10/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 085003268 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 085003268 | 01 | IL | STATE OF ILLINOIS LICENSE | OTHER |