MEDICARE: ADVANCED FAMILY PRACTICE, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner

General Provider Information

NPI Number	:	1639003122
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED FAMILY PRACTICE, PLLC

Provider Business Mailing Address
First Line	:	1657 ARCADIA ST
Second Line	:
City	:	MORTON GROVE
State	:	IL
Zip	:	60053
Country	:	US
Telephone Number	:	210-269-6764
Fax Number	:	210-269-6764

Provider Business Practice Location Address
First Line	:	1657 ARCADIA ST
Second Line	:
City	:	MORTON GROVE
State	:	IL
Zip	:	60053
Country	:	US
Telephone Number	:	210-269-6764
Fax Number	:	210-269-6764

Authorized Official
Title or Position	:	OWNER
Name	:	GORDON MESA
Credential	:
Telephone Number	:	210-269-6764

Provider Enumeration Date	:	06/10/2026
Last Update Date	:	06/10/2026

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