Healthcare Provider Details

I. General information

NPI: 1235930462
Provider Name (Legal Business Name): MOQING QUAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2025
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 N WESTMORELAND RD # LEVEL1
LAKE FOREST IL
60045-1658
US

IV. Provider business mailing address

1000 N WESTMORELAND RD # LEVEL1
LAKE FOREST IL
60045-1658
US

V. Phone/Fax

Practice location:
  • Phone: 847-534-3278
  • Fax: 847-535-8590
Mailing address:
  • Phone: 847-534-3278
  • Fax: 847-535-8590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number101251
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085011994
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number033294
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: