Basic Information
Provider Information | |||||||||
NPI: | 1578642518 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BLANCO | ||||||||
FirstName: | MELISSA | ||||||||
MiddleName: | A | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MUENCHOW | ||||||||
OtherFirstName: | MELISSA | ||||||||
OtherMiddleName: | A | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1 WESTBROOK CORPORATE CTR 240 | ||||||||
Address2: |   | ||||||||
City: | WESTCHESTER | ||||||||
State: | IL | ||||||||
PostalCode: | 601545745 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7082362673 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 929 W HIGGINS RD | ||||||||
Address2: |   | ||||||||
City: | SCHAUMBURG | ||||||||
State: | IL | ||||||||
PostalCode: | 601953203 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8472854200 | ||||||||
FaxNumber: | 8478850130 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/02/2006 | ||||||||
LastUpdateDate: | 12/10/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 085-002766 | IL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | P00641695 | 01 | IL | MEDICARE RAILROAD | OTHER |