Healthcare Provider Details

I. General information

NPI: 1669997680
Provider Name (Legal Business Name): SHUXIA JIANG CSA; CSFA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2017
Last Update Date: 11/10/2021
Certification Date: 11/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

624 LILAS CT
NEW LENOX IL
60451-3453
US

IV. Provider business mailing address

624 LILAS CT
NEW LENOX IL
60451-3453
US

V. Phone/Fax

Practice location:
  • Phone: 507-383-3279
  • Fax: 815-417-9856
Mailing address:
  • Phone: 507-383-3279
  • Fax: 815-417-9856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number238000557
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: