Provider Demographics
NPI:1093885188
Name:AGBUNAG, DAVID P (PA-C)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:P
Last Name:AGBUNAG
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1 WESTBROOK CORPORATE CTR
Mailing Address - Street 2:#240
Mailing Address - City:WESTCHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:60154-5701
Mailing Address - Country:US
Mailing Address - Phone:708-236-2673
Mailing Address - Fax:708-236-2773
Practice Address - Street 1:1725 W HARRISON ST
Practice Address - Street 2:#1063
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3841
Practice Address - Country:US
Practice Address - Phone:312-243-4244
Practice Address - Fax:312-243-2744
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL085002886363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209118OtherMEDICARE PTAN LOCALITY 15
IL209119OtherMEDICARE PTAN LOCALITY 16
IL209118OtherMEDICARE PTAN LOCALITY 15
ILK32688Medicare PIN