MEDICARE: KARINA MARIEL CALDERON PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AS0400X	Surgical Physician Assistant	085.007044	IL
2	363A00000X	Physician Assistant	085.007044	IL

General Provider Information

NPI Number	:	1396304788
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KARINA MARIEL CALDERON PA-C

Provider Business Mailing Address
First Line	:	909 W BUENA AVE APT 3E
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-1693
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	610 S MAPLE AVE STE 3700
Second Line	:
City	:	OAK PARK
State	:	IL
Zip	:	60304-2806
Country	:	US
Telephone Number	:	708-660-6430
Fax Number	:	708-660-6447

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/10/2019
Last Update Date	:	03/04/2022

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