Provider Demographics
NPI:1366794190
Name:MYHA, FORTESA (PA)
Entity type:Individual
Prefix:
First Name:FORTESA
Middle Name:
Last Name:MYHA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:900 S FRONTAGE RD STE 325
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-4907
Mailing Address - Country:US
Mailing Address - Phone:630-972-8228
Mailing Address - Fax:630-972-8229
Practice Address - Street 1:800 BIESTERFIELD RD STE G01
Practice Address - Street 2:
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-3372
Practice Address - Country:US
Practice Address - Phone:847-981-3680
Practice Address - Fax:847-956-5122
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-03
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL085006125363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILDS2377OtherRRMC GROUP PTAN
IL1720371669OtherGROUP PRACTICE NPI