Provider Demographics
NPI:1902890932
Name:NOONAN, SHERI L (PA-C)
Entity type:Individual
Prefix:
First Name:SHERI
Middle Name:L
Last Name:NOONAN
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 1:1505 EASTLAND DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-7906
Mailing Address - Country:US
Mailing Address - Phone:309-662-5506
Mailing Address - Fax:309-662-5443
Practice Address - Street 1:1505 EASTLAND DR
Practice Address - Street 2:SUITE 210
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-7906
Practice Address - Country:US
Practice Address - Phone:309-662-5506
Practice Address - Fax:309-662-5443
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085000754363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
085000754000OtherOSF HEALTH PLANS
278668OtherPERSONAL CARE
IL0104OtherJOHN DEERE HEALTH PLAN
342443OtherHEALTHLINK
038447OtherHEALTH ALLIANCE PROVIDER
37945OtherTRICARE
IL05732036OtherBLUE SHIELD GROUP NUMBER
37945OtherTRICARE
S06460Medicare UPIN
038447OtherHEALTH ALLIANCE PROVIDER