Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080P0201X | Pediatric Allergist | 036083010 | IL |
NPI | 1083674048 |
---|---|
Provider Name | Jacqueline Ann Pongracic |
First Address | Chicago, IL 60614 |
Second Address | Chicago, IL 60614 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/03/2006 |
Last Update Date | 21/09/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036083010 | (05) | IL |
E56819 | (02) |