Healthcare Provider Details

I. General information

NPI: 1598263899
Provider Name (Legal Business Name): ANDRIY KHLOPAS NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2018
Last Update Date: 04/06/2022
Certification Date: 04/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3412 W. FULLERTON AVE
CHICAGO IL
60647-2416
US

IV. Provider business mailing address

3412 W. FULLERTON .AVE.
CHICAGO IL
60647-2416
US

V. Phone/Fax

Practice location:
  • Phone: 773-235-8000
  • Fax: 773-486-9320
Mailing address:
  • Phone: 773-235-8000
  • Fax: 773-486-9320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number99083662A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number277.000785
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: