Provider Demographics
NPI:1760495410
Name:RAETZ, PATRICIA A (BSN/MSN/APN)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:A
Last Name:RAETZ
Suffix:
Gender:F
Credentials:BSN/MSN/APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 WINFIELD ROAD
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190
Mailing Address - Country:US
Mailing Address - Phone:630-614-4066
Mailing Address - Fax:630-614-4069
Practice Address - Street 1:259 E ERIE ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611
Practice Address - Country:US
Practice Address - Phone:312-695-8143
Practice Address - Fax:312-695-4430
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209001060364SN0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SN0800XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistNeuroscience
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0222075OtherBLUE CROSS GROUP NUMBER
IL36-3149833OtherTAX IDENTIFICATION NUMBER
ILP00686148OtherMEDICARE RAILROAD
IL3631498336019001OtherCDPG HFS PAYEE ID
ILCA4748OtherMEDICARE RR GROUP NUMBER
IL$$$$$$$$$001Medicaid
ILK31459Medicare PIN