Provider Demographics
NPI:1144452327
Name:MARITOTE, AMY L (PA)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:MARITOTE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2791 STOCKBERRY LN
Mailing Address - Street 2:
Mailing Address - City:WEST CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60185-6197
Mailing Address - Country:US
Mailing Address - Phone:630-269-7231
Mailing Address - Fax:
Practice Address - Street 1:1325 N HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-1449
Practice Address - Country:US
Practice Address - Phone:630-859-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-20
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003479363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085003479OtherSTATE LICENSE NUMBER