Healthcare Provider Details

I. General information

NPI: 1205688967
Provider Name (Legal Business Name): JOSEPH MOUNTAIN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2024
Last Update Date: 06/19/2024
Certification Date: 06/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 N CLAREMONT AVE APT 2
CHICAGO IL
60618-6232
US

IV. Provider business mailing address

3300 N CLAREMONT AVE APT 2
CHICAGO IL
60618-6232
US

V. Phone/Fax

Practice location:
  • Phone: 651-999-9605
  • Fax:
Mailing address:
  • Phone: 651-999-9605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: