Provider Demographics
NPI:1508073198
Name:ASTACIO, MARIO JOSE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MARIO
Middle Name:JOSE
Last Name:ASTACIO
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 1:36W649 WINDING TRL
Mailing Address - Street 2:
Mailing Address - City:WEST DUNDEE
Mailing Address - State:IL
Mailing Address - Zip Code:60118-9350
Mailing Address - Country:US
Mailing Address - Phone:224-558-5493
Mailing Address - Fax:224-220-0840
Practice Address - Street 1:1140 N MCLEAN BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-1782
Practice Address - Country:US
Practice Address - Phone:224-523-8971
Practice Address - Fax:224-220-0840
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2014-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-002516363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085-002516OtherSTATE PROVIDER LICENCE
IL962341Medicare PIN