Healthcare Provider Details

I. General information

NPI: 1992139281
Provider Name (Legal Business Name): KRISTINE BOWERSOX PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2013
Last Update Date: 11/21/2025
Certification Date: 11/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 S MARYLAND AVE
CHICAGO IL
60637-1443
US

IV. Provider business mailing address

1000 N WESTMORELAND RD
LAKE FOREST IL
60045-1658
US

V. Phone/Fax

Practice location:
  • Phone: 888-824-0200
  • Fax:
Mailing address:
  • Phone: 847-234-5600
  • Fax: 847-535-7203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085004671
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: