Provider Demographics
NPI:1528306008
Name:SHARMA, PETULA
Entity type:Individual
Prefix:
First Name:PETULA
Middle Name:
Last Name:SHARMA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PETULA
Other - Middle Name:MOUSTOGIANNIS
Other - Last Name:SHARMA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:709 BROUGHAM LN
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-2676
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:530 N CASS AVE
Practice Address - Street 2:
Practice Address - City:WESTMONT
Practice Address - State:IL
Practice Address - Zip Code:60559-1503
Practice Address - Country:US
Practice Address - Phone:630-968-1800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-17
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.010135367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered