Healthcare Provider Details

I. General information

NPI: 1528857729
Provider Name (Legal Business Name): MAURICIO GARCIA PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2025
Last Update Date: 05/05/2025
Certification Date: 05/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3533 W NORTH AVE
CHICAGO IL
60647-7573
US

IV. Provider business mailing address

2015 W 18TH PL
CHICAGO IL
60608-2707
US

V. Phone/Fax

Practice location:
  • Phone: 773-388-1600
  • Fax:
Mailing address:
  • Phone: 708-856-1428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.011189
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: