Provider Demographics
NPI:1154605392
Name:HOMMES, CHRISTIAN MARK (PA-C)
Entity type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:MARK
Last Name:HOMMES
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 1:3208 N SEMINARY AVE
Mailing Address - Street 2:APARTMENT 1R
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-6640
Mailing Address - Country:US
Mailing Address - Phone:978-870-3831
Mailing Address - Fax:
Practice Address - Street 1:7411 LAKE ST
Practice Address - Street 2:SUITE 2100
Practice Address - City:RIVER FOREST
Practice Address - State:IL
Practice Address - Zip Code:60305-1876
Practice Address - Country:US
Practice Address - Phone:708-488-1010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-06
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004121363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant