Provider Demographics
NPI:1447728183
Name:MERCADO, PAOLO PETILLA (APN)
Entity type:Individual
Prefix:MR
First Name:PAOLO
Middle Name:PETILLA
Last Name:MERCADO
Suffix:
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3076 NICKLAUS LN
Mailing Address - Street 2:
Mailing Address - City:WADSWORTH
Mailing Address - State:IL
Mailing Address - Zip Code:60083-8944
Mailing Address - Country:US
Mailing Address - Phone:224-388-1215
Mailing Address - Fax:
Practice Address - Street 1:1324 N SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-2161
Practice Address - Country:US
Practice Address - Phone:847-360-2860
Practice Address - Fax:847-625-6057
Is Sole Proprietor?:No
Enumeration Date:2018-11-12
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209018353363LF0000X
WI13217-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner