Healthcare Provider Details

I. General information

NPI: 1619441920
Provider Name (Legal Business Name): JEVON HUANG PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2019
Last Update Date: 02/28/2022
Certification Date: 02/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9556 MANCHESTER RD
SAINT LOUIS MO
63119-1313
US

IV. Provider business mailing address

1333 S WABASH AVE
CHICAGO IL
60605-2549
US

V. Phone/Fax

Practice location:
  • Phone: 636-220-9333
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085008582
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: