Provider Demographics
NPI:1962026450
Name:STAVROS, AIDAN KENNEDY (PA-C)
Entity type:Individual
Prefix:
First Name:AIDAN
Middle Name:KENNEDY
Last Name:STAVROS
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:PO BOX 735263
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5263
Mailing Address - Country:US
Mailing Address - Phone:877-632-6637
Mailing Address - Fax:708-409-5179
Practice Address - Street 1:1611 W HARRISON ST STE 400
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4861
Practice Address - Country:US
Practice Address - Phone:877-632-6637
Practice Address - Fax:708-409-5179
Is Sole Proprietor?:No
Enumeration Date:2020-06-01
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10004381A363A00000X
IL085008407363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant