Provider Demographics
NPI:1134173479
Name:KABARA, POLLYANNA (PA-C)
Entity type:Individual
Prefix:
First Name:POLLYANNA
Middle Name:
Last Name:KABARA
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:LAKESIDE PEDIATRICS
Mailing Address - Street 2:8600 75TH STREET
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142
Mailing Address - Country:US
Mailing Address - Phone:262-652-9430
Mailing Address - Fax:262-652-9433
Practice Address - Street 1:LAKESIDE PEDIATRICS
Practice Address - Street 2:8600 75TH STREET
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142
Practice Address - Country:US
Practice Address - Phone:262-652-9430
Practice Address - Fax:262-652-9433
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1389363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1134173479Medicaid
008006261XOtherHUMANA
P37390Medicare UPIN
WI1134173479Medicaid