Provider Demographics
NPI:1538386149
Name:KOVACIC, KATHERINE L (PA-C)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:L
Last Name:KOVACIC
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:L
Other - Last Name:SEDIVY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1000 N WESTMORELAND RD
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1658
Mailing Address - Country:US
Mailing Address - Phone:847-535-6793
Mailing Address - Fax:847-535-6867
Practice Address - Street 1:1000 N WESTMORELAND RD
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1658
Practice Address - Country:US
Practice Address - Phone:847-535-6793
Practice Address - Fax:847-535-6867
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002833363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1538386149Medicaid