MEDICARE: KATARZYNA B IWANICKI P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	085-002648	IL

General Provider Information

NPI Number	:	1760532790
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATARZYNA B IWANICKI P.A.

Provider Business Mailing Address
First Line	:	6127 GREEN BAY RD STE 100
Second Line	:
City	:	KENOSHA
State	:	WI
Zip	:	53142-2941
Country	:	US
Telephone Number	:	262-652-2887
Fax Number	:	262-764-0224

Provider Business Practice Location Address
First Line	:	250 W KENSINGTON RD STE 3B
Second Line	:
City	:	MOUNT PROSPECT
State	:	IL
Zip	:	60056-1292
Country	:	US
Telephone Number	:	622-652-2887
Fax Number	:	262-764-0224

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/11/2007
Last Update Date	:	09/03/2021

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