Provider Demographics
NPI:1730600271
Name:BLETHEN, LIESL MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:LIESL
Middle Name:MARIE
Last Name:BLETHEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LIESL
Other - Middle Name:MARIE
Other - Last Name:EURICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1051 W RAND RD # 110
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60004-2315
Mailing Address - Country:US
Mailing Address - Phone:847-618-9292
Mailing Address - Fax:847-618-9294
Practice Address - Street 1:1051 W RAND RD # 110
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60004-2315
Practice Address - Country:US
Practice Address - Phone:847-618-9292
Practice Address - Fax:847-618-9294
Is Sole Proprietor?:No
Enumeration Date:2017-07-06
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.006257363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085006257OtherSTATE LICENSE