Individual
TAJ GUBATANGA
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
CRNA
Contact information
Practice address
2160 S 1ST AVE, MAYWOOD, IL 60153-3328
(312) 774-6297
Mailing address
2160 S 1ST AVE, MAYWOOD, IL 60153-3328
(708) 216-9000
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
28206360A
IN
367500000X
Certified Registered Nurse Anesthetist
Primary
209024958
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1229
BIRTHDATE
—
Enumeration date
09/08/2021
Last updated
05/31/2022
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