Provider Demographics
NPI:1912057803
Name:EHRHARDT, SARAH JANE (PA-C)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:JANE
Last Name:EHRHARDT
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 1:1801 W TAYLOR ST
Mailing Address - Street 2:1-E OCC
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4795
Mailing Address - Country:US
Mailing Address - Phone:312-355-5004
Mailing Address - Fax:312-355-1515
Practice Address - Street 1:9921 SOUTHWEST HWY
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-3767
Practice Address - Country:US
Practice Address - Phone:708-499-5678
Practice Address - Fax:708-499-5685
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.002840363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL1068005Medicare PIN