Healthcare Provider Details

I. General information

NPI: 1770452583
Provider Name (Legal Business Name): MARTINA KOTRBA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2025
Last Update Date: 03/06/2026
Certification Date: 03/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2937 N IL ROUTE 178 UNIT 5
UTICA IL
61373-9708
US

IV. Provider business mailing address

2937 N IL ROUTE 178 UNIT 5
UTICA IL
61373-9708
US

V. Phone/Fax

Practice location:
  • Phone: 815-664-5367
  • Fax: 815-664-5204
Mailing address:
  • Phone: 815-664-5367
  • Fax: 815-664-5204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.011653
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: