Provider Demographics
NPI:1780130682
Name:MCGOVERN, KATHLEEN MARGARET (PA-C)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARGARET
Last Name:MCGOVERN
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 1:1860 PAYSPHERE CIR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-1782
Mailing Address - Country:US
Mailing Address - Phone:630-469-2000
Mailing Address - Fax:
Practice Address - Street 1:430 WARRENVILLE RD # 230
Practice Address - Street 2:
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532-1348
Practice Address - Country:US
Practice Address - Phone:630-693-6437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-30
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085005947363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
4025370OtherILLINOIS DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION