Provider Demographics
NPI:1326028143
Name:BURNS, KEVIN M (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:M
Last Name:BURNS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7402 E RIVERSIDE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-5630
Mailing Address - Country:US
Mailing Address - Phone:815-226-9642
Mailing Address - Fax:815-226-9672
Practice Address - Street 1:7402 E RIVERSIDE BLVD
Practice Address - Street 2:
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-5630
Practice Address - Country:US
Practice Address - Phone:815-226-9642
Practice Address - Fax:815-226-9672
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP17800Medicare UPIN
IL585530Medicare ID - Type Unspecified