Basic Information
| Provider Information | |||||||||
| NPI: | 1093885188 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AGBUNAG | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | P. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 WESTBROOK CORPORATE CTR | ||||||||
| Address2: | #240 | ||||||||
| City: | WESTCHESTER | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601545701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7082362673 | ||||||||
| FaxNumber: | 7082362773 | ||||||||
| Practice Location | |||||||||
| Address1: | 1725 W HARRISON ST | ||||||||
| Address2: | #1063 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606123841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3122434244 | ||||||||
| FaxNumber: | 3122432744 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 07/25/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 085002886 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 209118 | 01 | IL | MEDICARE PTAN LOCALITY 15 | OTHER | 209119 | 01 | IL | MEDICARE PTAN LOCALITY 16 | OTHER |