Basic Information
| Provider Information | |||||||||
| NPI: | 1578642377 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SALAZAR | ||||||||
| FirstName: | MARISA | ||||||||
| MiddleName: | A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 29373 NETWORK PL | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606731293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473905900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 522 TORRENCE AVE | ||||||||
| Address2: | |||||||||
| City: | CALUMET CITY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604093216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003238622 | ||||||||
| FaxNumber: | 2242250388 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2006 | ||||||||
| LastUpdateDate: | 05/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 209005122 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 209005122 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.