Healthcare Provider Details

I. General information

NPI: 1487333415
Provider Name (Legal Business Name): ANDY VAZQUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2023
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 S MARYLAND AVE
CHICAGO IL
60637-1443
US

IV. Provider business mailing address

5220 ESSEN LN
BATON ROUGE LA
70809-3542
US

V. Phone/Fax

Practice location:
  • Phone: 888-824-0200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209032171
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number9427200
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: