Provider Demographics
NPI:1376166264
Name:BOCANEGRA CORDOVA, CARLOS RODOLFO (PA-C)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:RODOLFO
Last Name:BOCANEGRA CORDOVA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:CARLOS
Other - Middle Name:R
Other - Last Name:BOCANEGRA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:819 BLOOMINGTON RD
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-2101
Mailing Address - Country:US
Mailing Address - Phone:217-356-1558
Mailing Address - Fax:
Practice Address - Street 1:819 BLOOMINGTON RD
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-2101
Practice Address - Country:US
Practice Address - Phone:217-356-1558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-26
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.007669363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant