Healthcare Provider Details

I. General information

NPI: 1124019286
Provider Name (Legal Business Name): LAURA P LEE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURIE P MENG PA-C

II. Dates (important events)

Enumeration Date: 10/28/2005
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3101 FIELDS SOUTH DR
CHAMPAIGN IL
61822-3743
US

IV. Provider business mailing address

101 W UNIVERSITY AVE
CHAMPAIGN IL
61820-3909
US

V. Phone/Fax

Practice location:
  • Phone: 217-366-6162
  • Fax: 217-366-5642
Mailing address:
  • Phone: 217-366-6162
  • Fax: 217-366-5642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085-002082
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085002082
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: