Provider Demographics
NPI:1598052458
Name:MISEK, KATHLEEN E (PA)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:E
Last Name:MISEK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:E
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1725 W HARRISON ST
Mailing Address - Street 2:SUITE 1010
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3841
Mailing Address - Country:US
Mailing Address - Phone:312-942-5904
Mailing Address - Fax:312-563-2371
Practice Address - Street 1:1725 W HARRISON ST
Practice Address - Street 2:SUITE 1010
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3841
Practice Address - Country:US
Practice Address - Phone:312-942-5904
Practice Address - Fax:312-563-2371
Is Sole Proprietor?:No
Enumeration Date:2011-06-29
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-003607363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant