Provider Demographics
NPI:1992453047
Name:DYSERT, ELENA (PA-C)
Entity type:Individual
Prefix:
First Name:ELENA
Middle Name:
Last Name:DYSERT
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 1:676 N SAINT CLAIR ST STE 14-044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2927
Mailing Address - Country:US
Mailing Address - Phone:312-908-8163
Mailing Address - Fax:312-695-1394
Practice Address - Street 1:676 N SAINT CLAIR ST STE 14-044
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2927
Practice Address - Country:US
Practice Address - Phone:312-908-8163
Practice Address - Fax:312-695-1394
Is Sole Proprietor?:No
Enumeration Date:2022-03-16
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085008865363A00000X
PAMA063222363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant