Provider Demographics
NPI:1437216165
Name:FEDOR, DOROTHY ANNE (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:DOROTHY
Middle Name:ANNE
Last Name:FEDOR
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:DOROTHY
Other - Middle Name:ANNE
Other - Last Name:BORKOWICZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:25 N WINFIELD RD
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190-1295
Mailing Address - Country:US
Mailing Address - Phone:630-933-4480
Mailing Address - Fax:630-933-2009
Practice Address - Street 1:25 N WINFIELD RD
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190
Practice Address - Country:US
Practice Address - Phone:630-933-4480
Practice Address - Fax:630-933-2009
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001477363AS0400X, 363A00000X
IN10001099A363AS0400X
WI2687-023363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL206147105OtherMEDICARE PTAN (INDIVIDUAL)
WI1437216165Medicaid
IL206147OtherMEDICARE PTAN (GROUP)
ILL90574Medicare PIN
IL206147OtherMEDICARE PTAN (GROUP)
ILP00744458Medicare PIN
WI1437216165Medicaid