Healthcare Provider Details

I. General information

NPI: 1396940375
Provider Name (Legal Business Name): JOY A DERUSHA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2007
Last Update Date: 06/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1029 EAST 130TH STREET
CHICAGO IL
60643-4039
US

IV. Provider business mailing address

1029 EAST 130TH STREET
CHICAGO IL
60643-4039
US

V. Phone/Fax

Practice location:
  • Phone: 773-387-2519
  • Fax:
Mailing address:
  • Phone: 773-995-6300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.002734
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number10000869A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: