Provider Demographics
NPI:1760532790
Name:IWANICKI, KATARZYNA B (PA)
Entity Type:Individual
Prefix:
First Name:KATARZYNA
Middle Name:B
Last Name:IWANICKI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KATARZYNA
Other - Middle Name:
Other - Last Name:SMIALEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:6127 GREEN BAY RD STE 100
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-2941
Mailing Address - Country:US
Mailing Address - Phone:262-652-2887
Mailing Address - Fax:262-764-0224
Practice Address - Street 1:250 W KENSINGTON RD STE 3B
Practice Address - Street 2:
Practice Address - City:MOUNT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-1292
Practice Address - Country:US
Practice Address - Phone:622-652-2887
Practice Address - Fax:262-764-0224
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-002648363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK35616Medicare PIN
IL767190Medicare ID - Type UnspecifiedMEDICARE GROUP #
ILCF4186Medicare ID - Type UnspecifiedRR MEDICARE GROUP #
ILQ76012Medicare UPIN