Healthcare Provider Details

I. General information

NPI: 1871244426
Provider Name (Legal Business Name): JONATHAN P RUIZ CSFA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2022
Last Update Date: 07/18/2023
Certification Date: 07/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 LIGHT RD APT 103
OSWEGO IL
60543-9013
US

IV. Provider business mailing address

1900 LIGHT RD APT 103
OSWEGO IL
60543-9013
US

V. Phone/Fax

Practice location:
  • Phone: 815-341-2599
  • Fax:
Mailing address:
  • Phone: 815-341-2599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number238000706
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: