Healthcare Provider Details

I. General information

NPI: 1205348976
Provider Name (Legal Business Name): JOHANNA CAROLINA MONTOYA CASTILLO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2355 S WESTERN AVE
CHICAGO IL
60608-3837
US

IV. Provider business mailing address

966 W 21ST ST
CHICAGO IL
60608-4511
US

V. Phone/Fax

Practice location:
  • Phone: 773-254-1400
  • Fax:
Mailing address:
  • Phone: 773-254-1400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085006409
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: