Provider Demographics
NPI:1083937338
Name:MCKINLEY, HEATHER (PHYSICIAN ASSITANT)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:MCKINLEY
Suffix:
Gender:F
Credentials:PHYSICIAN ASSITANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:259 E ERIE SUITE 1300
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611
Mailing Address - Country:US
Mailing Address - Phone:312-695-6800
Mailing Address - Fax:312-695-2771
Practice Address - Street 1:311 WEST VERMILION
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832
Practice Address - Country:US
Practice Address - Phone:217-431-7650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-01
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL85003691363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0533210001Medicare NSC