Provider Demographics
NPI:1235290883
Name:DISANTO, RICHARD A (PA-C)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:DISANTO
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 1:5201 WILLOW SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525
Mailing Address - Country:US
Mailing Address - Phone:708-579-0018
Mailing Address - Fax:708-579-7571
Practice Address - Street 1:5201 WILLOW SPRINGS RD
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-6537
Practice Address - Country:US
Practice Address - Phone:708-579-0018
Practice Address - Fax:708-579-7571
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1046964363A00000X
IL085001519363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1046964OtherNCCPA
403270Medicare ID - Type Unspecified
959420002Medicare PIN