Healthcare Provider Details

I. General information

NPI: 1487484390
Provider Name (Legal Business Name): LUCIA GURROLA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2024
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5635 W BELMONT AVE
CHICAGO IL
60634-4384
US

IV. Provider business mailing address

2458 W CULLOM AVE APT 1
CHICAGO IL
60618-1604
US

V. Phone/Fax

Practice location:
  • Phone: 773-736-1830
  • Fax:
Mailing address:
  • Phone: 773-403-4500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.010483
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: