Healthcare Provider Details

I. General information

NPI: 1992072649
Provider Name (Legal Business Name): KRISTEN L DOLDER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2011
Last Update Date: 05/14/2020
Certification Date: 05/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 RYAN PKWY
ALGONQUIN IL
60102-4527
US

IV. Provider business mailing address

1340 RYAN PKWY
ALGONQUIN IL
60102-4527
US

V. Phone/Fax

Practice location:
  • Phone: 815-276-0150
  • Fax: 877-461-6742
Mailing address:
  • Phone: 815-276-0150
  • Fax: 877-461-6742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085004109
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: