Healthcare Provider Details

I. General information

NPI: 1508253410
Provider Name (Legal Business Name): HAZEL DHATES ASUNIO DOMINGO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2015
Last Update Date: 08/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 E ERIE ST FL 16
CHICAGO IL
60611-2987
US

IV. Provider business mailing address

676 N SAINT CLAIR ST STE 2000
CHICAGO IL
60611-3147
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-5620
  • Fax: 312-695-0042
Mailing address:
  • Phone: 312-695-4837
  • Fax: 312-695-0042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.0007019
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: