Provider Demographics
NPI:1124019286
Name:LEE, LAURA P (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:P
Last Name:LEE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:LAURIE
Other - Middle Name:P
Other - Last Name:MENG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:803 ILLINI DRIVE
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IL
Mailing Address - Zip Code:61727
Mailing Address - Country:US
Mailing Address - Phone:217-935-7037
Mailing Address - Fax:217-935-7047
Practice Address - Street 1:1111 N STATE ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:IL
Practice Address - Zip Code:61856-1151
Practice Address - Country:US
Practice Address - Phone:217-762-2115
Practice Address - Fax:217-762-6165
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-002082363A00000X
IL085-02082363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK02626Medicare ID - Type UnspecifiedWPS MEDICARE#
ILK14803Medicare PIN
ILP00069829Medicare ID - Type UnspecifiedMC RAILROAD#
ILQ03673Medicare UPIN