Provider Demographics
NPI:1871824987
Name:RODRIGUEZ, EMILY C (PA-C)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:C
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 N WALL ST
Mailing Address - Street 2:SUITE P530
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-3483
Mailing Address - Country:US
Mailing Address - Phone:815-937-4006
Mailing Address - Fax:815-937-3850
Practice Address - Street 1:375 N WALL ST
Practice Address - Street 2:SUITE P530
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-3483
Practice Address - Country:US
Practice Address - Phone:815-937-4006
Practice Address - Fax:815-937-3850
Is Sole Proprietor?:No
Enumeration Date:2010-01-29
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003676363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085003676OtherLICENSE