Provider Demographics
NPI:1124771241
Name:ANTONUOS, MINA MILAD
Entity type:Individual
Prefix:
First Name:MINA
Middle Name:MILAD
Last Name:ANTONUOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6623 OAK FOREST AVE APT 12
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-3569
Mailing Address - Country:US
Mailing Address - Phone:708-518-5440
Mailing Address - Fax:
Practice Address - Street 1:6623 OAK FOREST AVE APT 12
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-3569
Practice Address - Country:US
Practice Address - Phone:708-518-5440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-28
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160008510225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant