Provider Demographics
NPI:1174757983
Name:TALISSE, CAROL E (PA)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:E
Last Name:TALISSE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:5019 N MOZART ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-3615
Mailing Address - Country:US
Mailing Address - Phone:773-293-3223
Mailing Address - Fax:773-293-4197
Practice Address - Street 1:5115 N FRANCISCO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-3611
Practice Address - Country:US
Practice Address - Phone:773-271-2225
Practice Address - Fax:773-271-1145
Is Sole Proprietor?:No
Enumeration Date:2009-05-07
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-003354363AS0400X
IL085003354363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085-003354OtherLICENSE