MEDICARE: GLADYS OTITO PA

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	363A00000X	Physician Assistant
2	363LF0000X	Family Nurse Practitioner	209025801	IL

General Provider Information

NPI Number	:	1871216374
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLADYS OTITO PA

Provider Business Mailing Address
First Line	:	6374 N LINCOLN AVE STE 201
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60659-1219
Country	:	US
Telephone Number	:	773-539-4145
Fax Number	:	773-539-1207

Provider Business Practice Location Address
First Line	:	6374 N LINCOLN AVE STE 201
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60659-1219
Country	:	US
Telephone Number	:	773-539-4145
Fax Number	:	773-539-1207

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

Provider Enumeration Date	:	09/21/2022
Last Update Date	:	09/21/2022

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Directions to “ GLADYS OTITO PA” Practice Location

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