Provider Demographics
NPI:1902507940
Name:PUSKAR, ANESSA
Entity Type:Individual
Prefix:
First Name:ANESSA
Middle Name:
Last Name:PUSKAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANESSA
Other - Middle Name:PUSKAR
Other - Last Name:TAWAKOL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1806 S VINE ST
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-5838
Mailing Address - Country:US
Mailing Address - Phone:630-777-8618
Mailing Address - Fax:
Practice Address - Street 1:611 W PARK ST
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2529
Practice Address - Country:US
Practice Address - Phone:217-383-3311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-16
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program