Basic Information
| Provider Information | |||||||||
| NPI: | 1295379543 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROJO | ||||||||
| FirstName: | CLARENCE | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9125 S PULASKI RD | ||||||||
| Address2: | |||||||||
| City: | EVERGREEN PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 608051441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084227715 | ||||||||
| FaxNumber: | 7084227816 | ||||||||
| Practice Location | |||||||||
| Address1: | 9125 S PULASKI RD | ||||||||
| Address2: | |||||||||
| City: | EVERGREEN PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 608051441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084227715 | ||||||||
| FaxNumber: | 7084227816 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2019 | ||||||||
| LastUpdateDate: | 07/29/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | 209012987 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
No ID Information.