Provider Demographics
NPI:1699386235
Name:BOCANEGRA, GUADALUPE
Entity type:Individual
Prefix:
First Name:GUADALUPE
Middle Name:
Last Name:BOCANEGRA
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 1:9241 S ROBERTS RD
Mailing Address - Street 2:
Mailing Address - City:HICKORY HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60457-3809
Mailing Address - Country:US
Mailing Address - Phone:630-809-9041
Mailing Address - Fax:
Practice Address - Street 1:9241 S ROBERTS RD
Practice Address - Street 2:
Practice Address - City:HICKORY HILLS
Practice Address - State:IL
Practice Address - Zip Code:60457-3809
Practice Address - Country:US
Practice Address - Phone:630-809-9041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-16
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX605340146N00000X
IL174400000X
MD20-0204R15246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL14D2190321OtherLABORATORY DIRECTOR
MD20-0204R15OtherPHLEBOTOMY
TX605340OtherEMT