Provider Demographics
NPI:1700821204
Name:ENGBLADE, DAVID CHANG (CRNA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:CHANG
Last Name:ENGBLADE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19624 GOVERNORS HWY
Mailing Address - Street 2:
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-2077
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19624 GOVERNORS HWY
Practice Address - Street 2:
Practice Address - City:FLOSSMOOR
Practice Address - State:IL
Practice Address - Zip Code:60422-2077
Practice Address - Country:US
Practice Address - Phone:708-798-5865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041314591367500000X
IL209-004913364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
K03657Medicare ID - Type Unspecified