Provider Demographics
NPI:1447558127
Name:PROKOP, KARIE LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:KARIE
Middle Name:LYNN
Last Name:PROKOP
Suffix:
Gender:F
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 1:105 S FIRST ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60481-8973
Mailing Address - Country:US
Mailing Address - Phone:815-476-5210
Mailing Address - Fax:815-476-4193
Practice Address - Street 1:105 S FIRST ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:IL
Practice Address - Zip Code:60481-8973
Practice Address - Country:US
Practice Address - Phone:815-476-5210
Practice Address - Fax:815-476-4193
Is Sole Proprietor?:No
Enumeration Date:2011-03-04
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.003995363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085.003995OtherSTATE LICENSE