Healthcare Provider Details

I. General information

NPI: 1306991690
Provider Name (Legal Business Name): MESHA N MCQUEEN PA-C, MMS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10432 S TORRENCE AVE
CHICAGO IL
60617-5756
US

IV. Provider business mailing address

10432 S TORRENCE AVE
CHICAGO IL
60617-5756
US

V. Phone/Fax

Practice location:
  • Phone: 773-459-6253
  • Fax: 773-768-4161
Mailing address:
  • Phone: 773-459-6253
  • Fax: 773-768-4161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: