Provider Demographics
NPI:1568962009
Name:JURGAITIS, MEGHAN NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:MEGHAN
Middle Name:NICOLE
Last Name:JURGAITIS
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 1:486 S PEACE RD
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-1655
Mailing Address - Country:US
Mailing Address - Phone:630-677-7555
Mailing Address - Fax:
Practice Address - Street 1:1672 S GALENA AVE
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-9611
Practice Address - Country:US
Practice Address - Phone:866-547-1417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-20
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085006512363A00000X
IL390200000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program