Provider Demographics
NPI:1386741163
Name:HARIRIE, JONATHAN (PA-C)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:HARIRIE
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 1:4201 W MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-8409
Mailing Address - Country:US
Mailing Address - Phone:815-759-3100
Mailing Address - Fax:815-363-9094
Practice Address - Street 1:4201 W MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-8409
Practice Address - Country:US
Practice Address - Phone:815-759-3100
Practice Address - Fax:815-363-9094
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085000692363A00000X
IL36-063591363A00000X
WI838363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42997300Medicaid
WI0039Medicare PIN
WI42997300Medicaid
WI0048Medicare PIN