Basic Information
| Provider Information | |||||||||
| NPI: | 1679710487 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHAVEZ-COLUMBO | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | ELENA | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MUNSTER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463214066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8663892727 | ||||||||
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| Practice Location | |||||||||
| Address1: | 801 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MUNSTER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463214066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8663892727 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2009 | ||||||||
| LastUpdateDate: | 08/10/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 71002800A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 209008072 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 000000621848 | 01 | IN | ANTHEM BCBS | OTHER | 200950870 | 05 | IN | MEDICAID |