Provider Demographics
NPI:1598416976
Name:NAMBO, ALEJANDRO (PA-C)
Entity Type:Individual
Prefix:
First Name:ALEJANDRO
Middle Name:
Last Name:NAMBO
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 1:3901 MERCY DR
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-3151
Mailing Address - Country:US
Mailing Address - Phone:815-363-9900
Mailing Address - Fax:
Practice Address - Street 1:3901 MERCY DR
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-3151
Practice Address - Country:US
Practice Address - Phone:815-363-9900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-17
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.008795363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty