Basic Information
| Provider Information | |||||||||
| NPI: | 1447993738 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ILLOVSKY | ||||||||
| FirstName: | GABRIEL | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 312 W ELTING ST | ||||||||
| Address2: | |||||||||
| City: | MACOMB | ||||||||
| State: | IL | ||||||||
| PostalCode: | 614551132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3092599090 | ||||||||
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| Practice Location | |||||||||
| Address1: | 901 W BEN WHITE BLVD | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787046903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124472211 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2022 | ||||||||
| LastUpdateDate: | 08/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 1071166 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 163W00000X | 1071166 | TX | N | Nursing Service Providers | Registered Nurse |
No ID Information.