Provider Demographics
NPI:1144659392
Name:LUPA, SARAH (MS, PA-C)
Entity type:Individual
Prefix:MISS
First Name:SARAH
Middle Name:
Last Name:LUPA
Suffix:
Gender:F
Credentials:MS, PA-C
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:
Other - Last Name:GROSSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1050 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-1835
Mailing Address - Country:US
Mailing Address - Phone:708-383-6366
Mailing Address - Fax:708-383-6449
Practice Address - Street 1:1050 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-1835
Practice Address - Country:US
Practice Address - Phone:708-383-6366
Practice Address - Fax:708-383-6449
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-08
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL85004722363AS0400X
IL385.003397363AS0400X
IL085004722363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty