Provider Demographics
NPI:1629619275
Name:VIZINTOS, MEGHANN REID (PA-C)
Entity Type:Individual
Prefix:
First Name:MEGHANN
Middle Name:REID
Last Name:VIZINTOS
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 1:1763 FREEDOM DR STE 117
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-3553
Mailing Address - Country:US
Mailing Address - Phone:630-687-9595
Mailing Address - Fax:
Practice Address - Street 1:1763 FREEDOM DR STE 117
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563
Practice Address - Country:US
Practice Address - Phone:630-687-9595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-04
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL85007364363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL85007364OtherILLINOIS PA LICENSE