Provider Demographics
NPI:1720225469
Name:BARROS, DIANA (CSA)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:BARROS
Suffix:
Gender:F
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4211 N CICERO AVE
Mailing Address - Street 2:SUITE #200
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-1651
Mailing Address - Country:US
Mailing Address - Phone:773-545-6900
Mailing Address - Fax:773-545-2220
Practice Address - Street 1:4211 N CICERO AVE
Practice Address - Street 2:SUITE #200
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-1651
Practice Address - Country:US
Practice Address - Phone:773-545-6900
Practice Address - Fax:773-545-2220
Is Sole Proprietor?:No
Enumeration Date:2009-01-16
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL08-211363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical