Provider Demographics
NPI:1285847384
Name:BONGIORNO, TRACY (PA-C)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:BONGIORNO
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 1:4727 WILLOW SPRINGS RD
Mailing Address - Street 2:UNIT 3S
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-6140
Mailing Address - Country:US
Mailing Address - Phone:708-482-1099
Mailing Address - Fax:708-482-0335
Practice Address - Street 1:4727 WILLOW SPRINGS RD
Practice Address - Street 2:UNIT 3S
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-6140
Practice Address - Country:US
Practice Address - Phone:708-482-1099
Practice Address - Fax:708-482-0335
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002051363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant