Healthcare Provider Details

I. General information

NPI: 1982460440
Provider Name (Legal Business Name): ANTONIYA GOSPODINOVA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2024
Last Update Date: 02/13/2026
Certification Date: 02/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

799 ROOSEVELT RD BLDG 4
GLEN ELLYN IL
60137-5908
US

IV. Provider business mailing address

799 ROOSEVELT RD BLDG 4
GLEN ELLYN IL
60137-5908
US

V. Phone/Fax

Practice location:
  • Phone: 708-356-2400
  • Fax: 708-356-2420
Mailing address:
  • Phone: 708-356-2400
  • Fax: 708-356-2420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: