Basic Information
| Provider Information | |||||||||
| NPI: | 1326137225 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CORDOVA | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | MAURICIO | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4300 COMMERCE CT | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | LISLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605323698 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309681881 | ||||||||
| FaxNumber: | 6309681719 | ||||||||
| Practice Location | |||||||||
| Address1: | 1259 RICKERT DR STE 101 | ||||||||
| Address2: | |||||||||
| City: | NAPERVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605408904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6303551300 | ||||||||
| FaxNumber: | 6303553273 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 12/13/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 85002213 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 085002213 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 085002213 | 05 | IL | MEDICAID | 970023229 | 01 | IL | RAILROAD MEDICARE | OTHER |