Healthcare Provider Details

I. General information

NPI: 1639003122
Provider Name (Legal Business Name): ADVANCED FAMILY PRACTICE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2026
Last Update Date: 06/10/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1657 ARCADIA ST
MORTON GROVE IL
60053
US

IV. Provider business mailing address

1657 ARCADIA ST
MORTON GROVE IL
60053
US

V. Phone/Fax

Practice location:
  • Phone: 210-269-6764
  • Fax: 210-269-6764
Mailing address:
  • Phone: 210-269-6764
  • Fax: 210-269-6764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: GORDON MESA
Title or Position: OWNER
Credential:
Phone: 210-269-6764