Provider Demographics
NPI:1235823824
Name:FLYNN, MEGAN CATHERINE (PA-C)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:CATHERINE
Last Name:FLYNN
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 1:41058 N WESTLAKE AVE
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:IL
Mailing Address - Zip Code:60002-8603
Mailing Address - Country:US
Mailing Address - Phone:224-678-4806
Mailing Address - Fax:
Practice Address - Street 1:13250 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53177-1516
Practice Address - Country:US
Practice Address - Phone:262-799-8700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-06
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI740123363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100247737Medicaid