Provider Demographics
NPI:1235154097
Name:BAKER, KRISTIN KEGLOVITZ (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:KEGLOVITZ
Last Name:BAKER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:L
Other - Last Name:KEGLOVITZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1730 W FARRAGUT AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-2012
Mailing Address - Country:US
Mailing Address - Phone:773-972-0724
Mailing Address - Fax:773-388-8936
Practice Address - Street 1:4025 N SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-2010
Practice Address - Country:US
Practice Address - Phone:773-388-8870
Practice Address - Fax:773-388-8936
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002665363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical