Provider Demographics
NPI:1699380139
Name:SABU, SANJAI NAICHERIL (PA-C)
Entity type:Individual
Prefix:MR
First Name:SANJAI
Middle Name:NAICHERIL
Last Name:SABU
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 1:675 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:312-695-1106
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:312-695-1106
Is Sole Proprietor?:No
Enumeration Date:2020-09-11
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA13924363A00000X
IL085010457363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX421268002OtherMEDICAID - CSHCN
TX421268001Medicaid