Provider Demographics
NPI:1568004463
Name:WINSTON, MEGHAN
Entity Type:Individual
Prefix:
First Name:MEGHAN
Middle Name:
Last Name:WINSTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1313 W RANDOLPH ST APT 214
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-1515
Mailing Address - Country:US
Mailing Address - Phone:214-803-3788
Mailing Address - Fax:
Practice Address - Street 1:3910 W OGDEN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-2470
Practice Address - Country:US
Practice Address - Phone:872-588-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085007294363A00000X
IL085.007294363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085007294OtherSTATE LICENSE
IL385005714OtherCS LICENSE
IL1165781OtherSPECIALTY BOARDS
ILMW5637814OtherDEA