Provider Demographics
NPI:1154954519
Name:LI, MEGAN (PA)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:LI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 DEARBORN DR
Mailing Address - Street 2:
Mailing Address - City:OLD TAPPAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07675-7320
Mailing Address - Country:US
Mailing Address - Phone:201-388-5974
Mailing Address - Fax:
Practice Address - Street 1:2701 QUEENS PLZ N
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-4020
Practice Address - Country:US
Practice Address - Phone:212-283-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-13
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024637363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant