Provider Demographics
NPI:1467633115
Name:GUR, SUJATA SHUKLA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:SUJATA
Middle Name:SHUKLA
Last Name:GUR
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:MRS
Other - First Name:SUJATA
Other - Middle Name:H
Other - Last Name:GUR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:2015 S FINLEY RD
Mailing Address - Street 2:#707
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-4828
Mailing Address - Country:US
Mailing Address - Phone:630-567-7851
Mailing Address - Fax:
Practice Address - Street 1:2013 MIDWEST RD
Practice Address - Street 2:
Practice Address - City:OAK BROOK
Practice Address - State:IL
Practice Address - Zip Code:60523-1312
Practice Address - Country:US
Practice Address - Phone:630-567-7851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-23
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209006824363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL7391001OtherMEDICARE PTAN