Provider Demographics
NPI:1073492880
Name:RUIZ, ANGEL (SA-C)
Entity type:Individual
Prefix:
First Name:ANGEL
Middle Name:
Last Name:RUIZ
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18761 CHESTNUT CT
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-9501
Mailing Address - Country:US
Mailing Address - Phone:786-448-9020
Mailing Address - Fax:
Practice Address - Street 1:18761 CHESTNUT CT
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-9501
Practice Address - Country:US
Practice Address - Phone:786-448-9020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-27
Last Update Date:2025-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL238.000847363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical