Provider Demographics
NPI:1730855677
Name:AGUSTIN, MARK PEREZ (ACNP)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:PEREZ
Last Name:AGUSTIN
Suffix:
Gender:M
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2650 RIDGE AVE.
Mailing Address - Street 2:DEPT. OF ANESTHESIA
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1057
Mailing Address - Country:US
Mailing Address - Phone:847-570-2760
Mailing Address - Fax:847-570-2921
Practice Address - Street 1:2650 RIDGE AVE.
Practice Address - Street 2:DEPT. OF ANESTHESIA
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-1057
Practice Address - Country:US
Practice Address - Phone:847-570-2760
Practice Address - Fax:847-570-2921
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-20
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL209019626363LA2100X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care