Provider Demographics
NPI:1225494883
Name:ILLERA, JHONATAN
Entity Type:Individual
Prefix:
First Name:JHONATAN
Middle Name:
Last Name:ILLERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20911 JAMAICA AVE
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11428-1548
Mailing Address - Country:US
Mailing Address - Phone:917-563-3388
Mailing Address - Fax:718-445-0951
Practice Address - Street 1:20911 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11428-1548
Practice Address - Country:US
Practice Address - Phone:917-563-3388
Practice Address - Fax:718-445-0951
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-12
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program