=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134828221
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAYSON LYN MARCY PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2023
-----------------------------------------------------
Last Update Date | 10/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2418 N ASHLAND AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60614-2021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-900-8330
-----------------------------------------------------
Fax | 312-761-1855
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 868 N WELLS ST APT 903
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60610-3675
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-440-1283
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 085011338
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------