Provider Demographics
NPI:1154607711
Name:WITTE, MONICA TARYN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MONICA
Middle Name:TARYN
Last Name:WITTE
Suffix:
Gender:F
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 1:4222 N LEAVITT ST
Mailing Address - Street 2:#2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-2908
Mailing Address - Country:US
Mailing Address - Phone:708-309-2694
Mailing Address - Fax:
Practice Address - Street 1:9600 GROSS POINT RD
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-1214
Practice Address - Country:US
Practice Address - Phone:847-677-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-27
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.004153363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical