Provider Demographics
NPI:1467446732
Name:VANBRUNT, KATHY M (PA)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:M
Last Name:VANBRUNT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KATHY
Other - Middle Name:M
Other - Last Name:WOJCIK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:15 S OLD RAND RD
Mailing Address - Street 2:
Mailing Address - City:LAKE ZURICH
Mailing Address - State:IL
Mailing Address - Zip Code:60047-2313
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15 S OLD RAND RD
Practice Address - Street 2:
Practice Address - City:LAKE ZURICH
Practice Address - State:IL
Practice Address - Zip Code:60047-2313
Practice Address - Country:US
Practice Address - Phone:847-438-2144
Practice Address - Fax:847-438-1597
Is Sole Proprietor?:No
Enumeration Date:2005-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0850003752363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical