Provider Demographics
NPI:1871675561
Name:KOWALCZUK, SARA JO (NP)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:JO
Last Name:KOWALCZUK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 E SUPERIOR ST FL 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2913
Mailing Address - Country:US
Mailing Address - Phone:312-926-5741
Mailing Address - Fax:312-926-4343
Practice Address - Street 1:233 E SUPERIOR ST FL 1
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2913
Practice Address - Country:US
Practice Address - Phone:312-926-5741
Practice Address - Fax:312-926-4343
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-001291363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILQ23880Medicare UPIN