Provider Demographics
NPI:1932981966
Name:MIYAKE, MADISON JEAN KEIKO (PA-C)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:JEAN KEIKO
Last Name:MIYAKE
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 1:212 W LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:TOWER LAKES
Mailing Address - State:IL
Mailing Address - Zip Code:60010-1131
Mailing Address - Country:US
Mailing Address - Phone:224-688-5717
Mailing Address - Fax:
Practice Address - Street 1:610 S MAPLE AVE STE 1500
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60304-2800
Practice Address - Country:US
Practice Address - Phone:312-563-3970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-16
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.009949363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical