Basic Information
| Provider Information | |||||||||
| NPI: | 1043509607 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAMTORA | ||||||||
| FirstName: | SEEMA | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7425 JANES AVE | ||||||||
| Address2: | |||||||||
| City: | WOODRIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605172356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153007764 | ||||||||
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| Practice Location | |||||||||
| Address1: | 17495 LA GRANGE RD | ||||||||
| Address2: | |||||||||
| City: | TINLEY PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604877581 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7082267000 | ||||||||
| FaxNumber: | 7083885672 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2011 | ||||||||
| LastUpdateDate: | 11/21/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 085004008 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.