Basic Information
| Provider Information | |||||||||
| NPI: | 1902972524 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HUISMAN | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KASTL | ||||||||
| OtherFirstName: | ANGELA | ||||||||
| OtherMiddleName: | MARIE | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 401 N MICHIGAN AVENUE | ||||||||
| Address2: | SUITE 1200 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606114264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126350973 | ||||||||
| FaxNumber: | 8132909691 | ||||||||
| Practice Location | |||||||||
| Address1: | 940 MAPLE AVENUE | ||||||||
| Address2: | |||||||||
| City: | HOMEWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604302061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087990244 | ||||||||
| FaxNumber: | 7087991505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2006 | ||||||||
| LastUpdateDate: | 10/29/2015 | ||||||||
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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 | 1284 | NE | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 085003225 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 085.003225 | 01 | IL | LICENSE | OTHER |