Healthcare Provider Details

I. General information

NPI: 1053188649
Provider Name (Legal Business Name): PEDRO LECHUGA BERNAL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2023
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 NE GLEN OAK AVE
PEORIA IL
61637-0001
US

IV. Provider business mailing address

530 NE GLEN OAK AVE
PEORIA IL
61637-0001
US

V. Phone/Fax

Practice location:
  • Phone: 309-624-0730
  • Fax: 309-655-6493
Mailing address:
  • Phone: 309-624-0730
  • Fax: 309-655-6493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085012395
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: