Basic Information
| Provider Information | |||||||||
| NPI: | 1730622283 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRIGAN | ||||||||
| FirstName: | LEIGH ANN | ||||||||
| MiddleName: | G. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LUTZ | ||||||||
| OtherFirstName: | LEIGH ANN | ||||||||
| OtherMiddleName: | G. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 775985 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606775985 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177706900 | ||||||||
| FaxNumber: | 3177706911 | ||||||||
| Practice Location | |||||||||
| Address1: | 17600 SHAMROCK BLVD STE 400A | ||||||||
| Address2: | |||||||||
| City: | WESTFIELD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460747002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177703777 | ||||||||
| FaxNumber: | 3172145691 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2016 | ||||||||
| LastUpdateDate: | 09/23/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 2625 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 300036285 | 05 | IN | MEDICAID |