Provider Demographics
NPI:1720408834
Name:MONDO, PHARES (CRNA)
Entity Type:Individual
Prefix:
First Name:PHARES
Middle Name:
Last Name:MONDO
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 E 22ND ST
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-6110
Mailing Address - Country:US
Mailing Address - Phone:630-960-9222
Mailing Address - Fax:
Practice Address - Street 1:3701 DOTY RD
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098-7509
Practice Address - Country:US
Practice Address - Phone:815-343-3170
Practice Address - Fax:630-874-2642
Is Sole Proprietor?:No
Enumeration Date:2014-04-16
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209011387367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered