Provider Demographics
NPI:1306278130
Name:IGANA, RAQUEL TAHUD (NP)
Entity type:Individual
Prefix:
First Name:RAQUEL
Middle Name:TAHUD
Last Name:IGANA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1818 E WINDSOR RD
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61802-9566
Mailing Address - Country:US
Mailing Address - Phone:217-255-9646
Mailing Address - Fax:217-326-1777
Practice Address - Street 1:611 W PARK ST
Practice Address - Street 2:BWPC
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2500
Practice Address - Country:US
Practice Address - Phone:217-383-6792
Practice Address - Fax:217-383-4752
Is Sole Proprietor?:No
Enumeration Date:2013-08-02
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILF1212018363LF0000X
IL209010213363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400093105Medicare UPIN