Basic Information
| Provider Information | |||||||||
| NPI: | 1134579196 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KROSS | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | RICHARD | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12251 S. 80TH AVE | ||||||||
| Address2: | SUITE 1630 | ||||||||
| City: | PALOS HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7089235173 | ||||||||
| FaxNumber: | 7089235018 | ||||||||
| Practice Location | |||||||||
| Address1: | 12251 S 80TH AVE STE 1630 | ||||||||
| Address2: | |||||||||
| City: | PALOS HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604631256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6306498972 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2016 | ||||||||
| LastUpdateDate: | 09/19/2017 | ||||||||
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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 | 363L00000X | 209.014337 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | F400410704 | 01 | IL | MEDICARE PTAN | OTHER | 209014337001 | 05 | IL | MEDICAID |