Provider Demographics
NPI:1265829113
Name:FARCUS, MATTHEW (CRNA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:FARCUS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1666 KIRSTEN LEE DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60481-4100
Mailing Address - Country:US
Mailing Address - Phone:815-791-6084
Mailing Address - Fax:
Practice Address - Street 1:30 WOODLAKE BLVD
Practice Address - Street 2:1304
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-6714
Practice Address - Country:US
Practice Address - Phone:815-791-6084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-17
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041382727163W00000X
WI193394163W00000X
IL209.012934367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse