Provider Demographics
NPI:1588465199
Name:PANIAGUA, JOAQUIN (RSA)
Entity type:Individual
Prefix:
First Name:JOAQUIN
Middle Name:
Last Name:PANIAGUA
Suffix:
Gender:
Credentials:RSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19015 S JODI RD STE H
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-8534
Mailing Address - Country:US
Mailing Address - Phone:708-995-5418
Mailing Address - Fax:832-804-8886
Practice Address - Street 1:19015 S JODI RD STE H
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-8534
Practice Address - Country:US
Practice Address - Phone:708-995-5418
Practice Address - Fax:832-804-8886
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-20
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL238000844246ZC0007X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant