Basic Information
| Provider Information | |||||||||
| NPI: | 1093225161 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCNICHOLS | ||||||||
| FirstName: | MEGAN | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MSPA, PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7156 W 127TH ST UNIT 300 | ||||||||
| Address2: | |||||||||
| City: | PALOS HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604631560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7082801003 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7156 W 127TH ST UNIT 300 | ||||||||
| Address2: | |||||||||
| City: | PALOS HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604631560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084802650 | ||||||||
| FaxNumber: | 7085752876 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2017 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 085.006337 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 085.006337 | 01 | IL | STATE OF ILLINOIS LICENSE | OTHER |