Provider Demographics
NPI:1124509773
Name:CONNOLLY, SARA BURKE (PA)
Entity type:Individual
Prefix:MS
First Name:SARA
Middle Name:BURKE
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:251 E HURON ST STE 5-704
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2908
Mailing Address - Country:US
Mailing Address - Phone:312-695-0061
Mailing Address - Fax:312-926-8341
Practice Address - Street 1:251 E HURON ST STE 5-704
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2908
Practice Address - Country:US
Practice Address - Phone:312-695-0061
Practice Address - Fax:312-926-8341
Is Sole Proprietor?:No
Enumeration Date:2018-08-22
Last Update Date:2025-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018034962363AM0700X, 363AM0700X
IL085006538363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO220060165Medicaid