Provider Demographics
NPI:1962483123
Name:LORENZ, ROBERT (PA-C)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:LORENZ
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 1:2650 RIDGE AVE STE 3507
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1778
Mailing Address - Country:US
Mailing Address - Phone:847-570-2868
Mailing Address - Fax:847-733-5005
Practice Address - Street 1:2650 RIDGE AVE STE 3507
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-1778
Practice Address - Country:US
Practice Address - Phone:847-570-2868
Practice Address - Fax:847-733-5005
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001935363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q44942Medicare UPIN
ILQ44942Medicare UPIN