Healthcare Provider Details

I. General information

NPI: 1922179357
Provider Name (Legal Business Name): LAURA JEAN CORRAL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 02/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 S MARYLAND AVE
CHICAGO IL
60637-1447
US

IV. Provider business mailing address

1509 CLUB DR
GLENDALE HEIGHTS IL
60139-3679
US

V. Phone/Fax

Practice location:
  • Phone: 773-702-1220
  • Fax:
Mailing address:
  • Phone: 404-695-1867
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085003798
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: