Provider Demographics
NPI:1255694568
Name:WYDRA, MARGUERITE A
Entity Type:Individual
Prefix:
First Name:MARGUERITE
Middle Name:A
Last Name:WYDRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1653 W. CONGRESS PKWY
Mailing Address - Street 2:622 MURDOCK
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612
Mailing Address - Country:US
Mailing Address - Phone:312-942-6194
Mailing Address - Fax:312-942-4370
Practice Address - Street 1:1653 W. CONGRESS PKWY
Practice Address - Street 2:622 MURDOCK
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612
Practice Address - Country:US
Practice Address - Phone:312-942-6194
Practice Address - Fax:312-942-4370
Is Sole Proprietor?:No
Enumeration Date:2012-06-21
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-008510364SP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatrics