Provider Demographics
NPI:1114578499
Name:TANTUWAYA, SONAM (PA-C)
Entity Type:Individual
Prefix:
First Name:SONAM
Middle Name:
Last Name:TANTUWAYA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9701 W HIGGINS RD STE 270
Mailing Address - Street 2:
Mailing Address - City:ROSEMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60018-4703
Mailing Address - Country:US
Mailing Address - Phone:847-653-0130
Mailing Address - Fax:
Practice Address - Street 1:9701 W HIGGINS RD STE 270
Practice Address - Street 2:
Practice Address - City:ROSEMONT
Practice Address - State:IL
Practice Address - Zip Code:60018-4703
Practice Address - Country:US
Practice Address - Phone:847-653-0130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-26
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.007163363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant