Provider Demographics
NPI:1891345294
Name:CHUA, MARK C (NP)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:C
Last Name:CHUA
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4632 CHURCH ST STE 101
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-1545
Mailing Address - Country:US
Mailing Address - Phone:847-768-1050
Mailing Address - Fax:847-768-1064
Practice Address - Street 1:4632 CHURCH ST STE 101
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-1545
Practice Address - Country:US
Practice Address - Phone:847-768-1050
Practice Address - Fax:847-768-1064
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-17
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95008812363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95008812OtherBOARD OF REGISTERED NURSING