Basic Information
| Provider Information | |||||||||
| NPI: | 1730855677 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AGUSTIN | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | PEREZ | ||||||||
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| Credential: | ACNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2650 RIDGE AVE. | ||||||||
| Address2: | DEPT. OF ANESTHESIA | ||||||||
| City: | EVANSTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 602011057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475702760 | ||||||||
| FaxNumber: | 8475702921 | ||||||||
| Practice Location | |||||||||
| Address1: | 2650 RIDGE AVE. | ||||||||
| Address2: | DEPT. OF ANESTHESIA | ||||||||
| City: | EVANSTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 602011057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475702760 | ||||||||
| FaxNumber: | 8475702921 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2021 | ||||||||
| LastUpdateDate: | 09/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 209019626 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363L00000X | 209019626 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.