Healthcare Provider Details

I. General information

NPI: 1922767904
Provider Name (Legal Business Name): JOHN MICHAEL AGSAO FERNANDEZ PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2021
Last Update Date: 12/17/2021
Certification Date: 12/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2655 W PETERSON AVE # 60659
CHICAGO IL
60659-4017
US

IV. Provider business mailing address

2655 W PETERSON AVE
CHICAGO IL
60659-4017
US

V. Phone/Fax

Practice location:
  • Phone: 224-715-6741
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160008094
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: