Healthcare Provider Details

I. General information

NPI: 1649731910
Provider Name (Legal Business Name): JAMES PEDRAZA JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2019
Last Update Date: 11/06/2023
Certification Date: 11/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4354 W 63RD ST
CHICAGO IL
60629-5039
US

IV. Provider business mailing address

4354 W 63RD ST
CHICAGO IL
60629-5039
US

V. Phone/Fax

Practice location:
  • Phone: 773-482-5800
  • Fax:
Mailing address:
  • Phone: 773-482-5800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License NumberSTUDENT
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209019464
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: