Healthcare Provider Details

I. General information

NPI: 1922727452
Provider Name (Legal Business Name): NEREZA MIA BURGOS APN-CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2022
Last Update Date: 08/13/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 RIDGE AVE. DEPARTMENT OF ANESTHESIA
EVANSTON IL
60201-1718
US

IV. Provider business mailing address

2650 RIDGE AVE. DEPARTMENT OF ANESTHESIA
EVANSTON IL
60201-1718
US

V. Phone/Fax

Practice location:
  • Phone: 847-570-2760
  • Fax: 847-570-2921
Mailing address:
  • Phone: 847-570-2760
  • Fax: 847-570-2921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.506593
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209030105
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: