MEDICARE: KATHY M VANBRUNT PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	0850003752	IL

General Provider Information

NPI Number	:	1467446732
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHY M VANBRUNT PA

Provider Business Mailing Address
First Line	:	15 S OLD RAND RD
Second Line	:
City	:	LAKE ZURICH
State	:	IL
Zip	:	60047-2313
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	15 S OLD RAND RD
Second Line	:
City	:	LAKE ZURICH
State	:	IL
Zip	:	60047-2313
Country	:	US
Telephone Number	:	847-438-2144
Fax Number	:	847-438-1597

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/01/2005
Last Update Date	:	07/08/2007

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