Healthcare Provider Details

I. General information

NPI: 1730855677
Provider Name (Legal Business Name): MARK PEREZ AGUSTIN ACNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2021
Last Update Date: 09/17/2021
Certification Date: 09/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 RIDGE AVE. DEPT. OF ANESTHESIA
EVANSTON IL
60201-1057
US

IV. Provider business mailing address

2650 RIDGE AVE. DEPT. OF ANESTHESIA
EVANSTON IL
60201-1057
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 Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number209019626
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209019626
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: