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General NPI Number Information
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NPI Number | 1255833695
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Entity Type | Individual
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Provider Name | MARISOL CHIRINOS TITO PA
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Gender | Female
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Dates
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Enumeration Date | 03/01/2018
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Last Update Date | 06/04/2025
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Provider Practice Location Address
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Address Line | 819 BLOOMINGTON RD
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City | CHAMPAIGN
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State | IL
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Zip | 61820-2101
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Country | US
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Telephone | 217-356-1558
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Fax |
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Provider Business Mailing Address
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Address Line | 611 W. PARK ST. FAPC
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City | URBANA
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State | IL
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Zip | 61801
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 085006525
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License Number State | IL
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