Provider Demographics
NPI:1326137225
Name:CORDOVA, SAMUEL MAURICIO (PA-C)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:MAURICIO
Last Name:CORDOVA
Suffix:
Gender:M
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 1:4300 COMMERCE CT
Mailing Address - Street 2:SUITE 230
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532-3698
Mailing Address - Country:US
Mailing Address - Phone:630-968-1881
Mailing Address - Fax:630-968-1719
Practice Address - Street 1:1259 RICKERT DR STE 101
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-8904
Practice Address - Country:US
Practice Address - Phone:630-355-1300
Practice Address - Fax:630-355-3273
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL85002213363AS0400X
IL085002213363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085002213Medicaid
IL970023229OtherRAILROAD MEDICARE
IL0371240002Medicare NSC
IL970023229OtherRAILROAD MEDICARE