Provider Demographics
NPI:1104176262
Name:OKIGAWA, ASHLEY L (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MRS
First Name:ASHLEY
Middle Name:L
Last Name:OKIGAWA
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:L
Other - Last Name:LUSTGARTEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:P A
Mailing Address - Street 1:1710 N RANDALL RD STE 140
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-9401
Mailing Address - Country:US
Mailing Address - Phone:224-293-1170
Mailing Address - Fax:847-289-0960
Practice Address - Street 1:1710 N RANDALL RD STE 140
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-9401
Practice Address - Country:US
Practice Address - Phone:224-293-1170
Practice Address - Fax:847-289-0960
Is Sole Proprietor?:No
Enumeration Date:2012-09-17
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363AS0400X
IL085004508363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085004508Medicaid
IL700860040Medicare PIN