Provider Demographics
NPI:1467785014
Name:TACDERAS, ANGELITO DARIEL (APN)
Entity Type:Individual
Prefix:MR
First Name:ANGELITO
Middle Name:DARIEL
Last Name:TACDERAS
Suffix:
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 430
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-0430
Mailing Address - Country:US
Mailing Address - Phone:618-997-1200
Mailing Address - Fax:618-997-1212
Practice Address - Street 1:3331 W DEYOUNG ST
Practice Address - Street 2:STE 308
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-5896
Practice Address - Country:US
Practice Address - Phone:618-997-1200
Practice Address - Fax:618-997-1212
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-15
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.007762363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILPENDINGMedicaid
ILPENDINGMedicaid