Provider Demographics
NPI:1154629541
Name:KOTHARI, ISHA (PA)
Entity Type:Individual
Prefix:
First Name:ISHA
Middle Name:
Last Name:KOTHARI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:311 S COUNTY FARM RD STE A
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-2477
Mailing Address - Country:US
Mailing Address - Phone:630-566-4585
Mailing Address - Fax:833-602-1648
Practice Address - Street 1:311 S COUNTY FARM RD STE A
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-2477
Practice Address - Country:US
Practice Address - Phone:630-566-4585
Practice Address - Fax:833-602-1648
Is Sole Proprietor?:No
Enumeration Date:2011-03-09
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL085004430363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant