Provider Demographics
NPI:1093180341
Name:JUAREZ, MELISSA (PA-C)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:JUAREZ
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 1:5235 S NATOMA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60638-1221
Mailing Address - Country:US
Mailing Address - Phone:630-397-8964
Mailing Address - Fax:
Practice Address - Street 1:5635 STATE RD
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:IL
Practice Address - Zip Code:60459-2051
Practice Address - Country:US
Practice Address - Phone:708-237-8918
Practice Address - Fax:708-237-8997
Is Sole Proprietor?:No
Enumeration Date:2015-12-10
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0004486363AM0700X
IL085.006241363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical