Healthcare Provider Details

I. General information

NPI: 1063408417
Provider Name (Legal Business Name): ELMER JOHN CAPINA PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 08/22/2025
Certification Date: 08/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 MCCLINTOCK DR SUITE 202
BURR RIDGE IL
60527-0872
US

IV. Provider business mailing address

901 MCCLINTOCK DR SUITE 202
BURR RIDGE IL
60527-0872
US

V. Phone/Fax

Practice location:
  • Phone: 888-220-6432
  • Fax: 630-654-4253
Mailing address:
  • Phone: 888-220-6432
  • Fax: 630-654-4253

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085-002220
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8502-23
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: