Provider Demographics
NPI:1568082659
Name:MCKENNA, MATTHEW JOHN (PA-C)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JOHN
Last Name:MCKENNA
Suffix:
Gender:M
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 1:830 W DIVERSEY PKWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-1454
Mailing Address - Country:US
Mailing Address - Phone:773-248-4150
Mailing Address - Fax:
Practice Address - Street 1:830 W DIVERSEY PKWY
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-1454
Practice Address - Country:US
Practice Address - Phone:773-248-4150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-20
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085007973363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant