Healthcare Provider Details

I. General information

NPI: 1447728183
Provider Name (Legal Business Name): PAOLO PETILLA MERCADO APN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2018
Last Update Date: 06/28/2023
Certification Date: 06/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1324 N SHERIDAN RD
WAUKEGAN IL
60085-2161
US

IV. Provider business mailing address

3076 NICKLAUS LN
WADSWORTH IL
60083-8944
US

V. Phone/Fax

Practice location:
  • Phone: 847-360-2860
  • Fax: 847-625-6057
Mailing address:
  • Phone: 224-388-1215
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number13217-33
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209018353
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: