Healthcare Provider Details

I. General information

NPI: 1528287422
Provider Name (Legal Business Name): KENNETH DEGNER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 11/16/2025
Certification Date: 01/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

431 W LIBERTY ST
WAUCONDA IL
60084-2452
US

IV. Provider business mailing address

PO BOX 6037
WAUCONDA IL
60084-6037
US

V. Phone/Fax

Practice location:
  • Phone: 847-526-2151
  • Fax: 847-526-2017
Mailing address:
  • Phone: 847-526-2151
  • Fax: 847-526-2017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085000019
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: