Provider Demographics
NPI:1609496405
Name:LOZADA, DEANA M (PA)
Entity Type:Individual
Prefix:
First Name:DEANA
Middle Name:M
Last Name:LOZADA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:DEANA
Other - Middle Name:
Other - Last Name:CANAVERAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:3860 W OGDEN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60623-2460
Mailing Address - Country:US
Mailing Address - Phone:872-588-3000
Mailing Address - Fax:
Practice Address - Street 1:3860 W OGDEN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-2460
Practice Address - Country:US
Practice Address - Phone:872-588-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-21
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085008051363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085008051OtherSTATE LICENSE
IL1158232OtherSPECIALTY BOARDS
IL385006172OtherCS LICENSE
ILMC6304529OtherDEA