Provider Demographics
NPI:1083609002
Name:MCAVOY, DIANE CAROL (PA-C)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:CAROL
Last Name:MCAVOY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 ITASCA PL UNIT 426
Mailing Address - Street 2:
Mailing Address - City:ITASCA
Mailing Address - State:IL
Mailing Address - Zip Code:60143-2575
Mailing Address - Country:US
Mailing Address - Phone:570-592-5607
Mailing Address - Fax:
Practice Address - Street 1:1 PARKVIEW PLZ
Practice Address - Street 2:
Practice Address - City:OAKBROOK TERRACE
Practice Address - State:IL
Practice Address - Zip Code:60181-4400
Practice Address - Country:US
Practice Address - Phone:312-945-7444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0007548363AM0700X
IL085009493363A00000X
IL085.009493363AM0700X
PAMA001866L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1035418490002Medicaid
PAP22259Medicare UPIN