Provider Demographics
NPI:1689436305
Name:ORTIZ, MARIO (PA-S2)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:ORTIZ
Suffix:
Gender:M
Credentials:PA-S2
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3603 W 53RD ST APT 5
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60632-3757
Mailing Address - Country:US
Mailing Address - Phone:773-954-6812
Mailing Address - Fax:
Practice Address - Street 1:3603 W 53RD ST APT 5
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60632-3757
Practice Address - Country:US
Practice Address - Phone:773-954-6812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-29
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant