Provider Demographics
NPI:1588034292
Name:CANNATARO, NICHOLAS (PA)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:CANNATARO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 REGENCY DR
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:IL
Mailing Address - Zip Code:60103-4442
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1355 REMINGTON RD
Practice Address - Street 2:
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60173-4832
Practice Address - Country:US
Practice Address - Phone:630-912-2930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-07
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.004609363A00000X
TXPA08929363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant