Provider Demographics
NPI:1306551486
Name:MACWAN, JOLLY P (NP)
Entity type:Individual
Prefix:MR
First Name:JOLLY
Middle Name:P
Last Name:MACWAN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8500 WAUKEGAN RD APT 13
Mailing Address - Street 2:
Mailing Address - City:MORTON GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60053-2204
Mailing Address - Country:US
Mailing Address - Phone:847-323-4491
Mailing Address - Fax:
Practice Address - Street 1:800 E WOODFIELD RD STE 113
Practice Address - Street 2:
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60173-4786
Practice Address - Country:US
Practice Address - Phone:847-686-6866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209026572363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily