Provider Demographics
NPI:1821766221
Name:VATANATUNYAKUM, MATT
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:
Last Name:VATANATUNYAKUM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 S ROSELLE RD
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60193-2925
Mailing Address - Country:US
Mailing Address - Phone:847-985-0600
Mailing Address - Fax:847-985-3786
Practice Address - Street 1:519 S ROSELLE RD
Practice Address - Street 2:
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60193-2925
Practice Address - Country:US
Practice Address - Phone:847-985-0600
Practice Address - Fax:847-985-3786
Is Sole Proprietor?:No
Enumeration Date:2021-08-31
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209025739363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209025739OtherSTATE LICENSE