Healthcare Provider Details

I. General information

NPI: 1093015448
Provider Name (Legal Business Name): KRISTINA REGINA GASPERS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTINA REGINA MALLEN PAC

II. Dates (important events)

Enumeration Date: 11/01/2010
Last Update Date: 09/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16519 S RTE 59
PLAINFIELD IL
60586-2606
US

IV. Provider business mailing address

16519 S RTE 59
PLAINFIELD IL
60586-2606
US

V. Phone/Fax

Practice location:
  • Phone: 630-646-5020
  • Fax: 630-646-5025
Mailing address:
  • Phone: 630-646-5020
  • Fax: 630-646-5025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085003877
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier01633203
Identifier TypeOTHER
Identifier StateIL
Identifier IssuerBCBS GROUP
# 2
Identifier10115176
Identifier TypeOTHER
Identifier StateIL
Identifier IssuerBCBS GROUP

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: