Provider Demographics
NPI:1104548015
Name:COLE, JOHN TYLER (PA-C)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:TYLER
Last Name:COLE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:675 N SAINT CLAIR ST STE 21-100
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-5970
Mailing Address - Country:US
Mailing Address - Phone:312-695-0990
Mailing Address - Fax:312-472-5270
Practice Address - Street 1:675 N SAINT CLAIR ST STE 21-100
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-5970
Practice Address - Country:US
Practice Address - Phone:312-695-0990
Practice Address - Fax:312-472-5270
Is Sole Proprietor?:No
Enumeration Date:2022-09-16
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
IL085009296363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant