Provider Demographics
NPI:1063922854
Name:FALCON, ANTHONY EDWARD (PA-C)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:EDWARD
Last Name:FALCON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4721 N MALDEN ST UNIT GN
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-7180
Mailing Address - Country:US
Mailing Address - Phone:917-604-3605
Mailing Address - Fax:
Practice Address - Street 1:12935 GREGORY ST
Practice Address - Street 2:
Practice Address - City:BLUE ISLAND
Practice Address - State:IL
Practice Address - Zip Code:60406-2428
Practice Address - Country:US
Practice Address - Phone:708-597-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-05
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085006340363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty