Healthcare Provider Details

I. General information

NPI: 1710223433
Provider Name (Legal Business Name): JUSTIN VRAGEL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2012
Last Update Date: 07/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5145 N CALIFORNIA AVE
CHICAGO IL
60625-3661
US

IV. Provider business mailing address

1447 W CORNELIA AVE APT 1
CHICAGO IL
60657-1326
US

V. Phone/Fax

Practice location:
  • Phone: 773-878-8200
  • Fax:
Mailing address:
  • Phone: 847-530-1774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085-004336
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: