Provider Demographics
NPI:1306172754
Name:FONTANA, KATE W
Entity type:Individual
Prefix:MS
First Name:KATE
Middle Name:W
Last Name:FONTANA
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KATE
Other - Middle Name:M
Other - Last Name:WEGLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:900 S FRONTAGE RD
Mailing Address - Street 2:SUITE 325
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-4903
Mailing Address - Country:US
Mailing Address - Phone:847-981-3680
Mailing Address - Fax:847-956-5122
Practice Address - Street 1:800 BIESTERFIELD RD STE G01
Practice Address - Street 2:WIMMER BUILDING
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-3372
Practice Address - Country:US
Practice Address - Phone:847-981-3680
Practice Address - Fax:847-956-5122
Is Sole Proprietor?:No
Enumeration Date:2009-10-20
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003615363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL6305021OtherMEDICARE PIN-LOC 15
ILP01058191OtherRRMC PTAN
ILIL6304021OtherMEDICARE PIN-LOC 16
IL1720371669OtherNPI GROUP PRACTICE