Provider Demographics
NPI:1326525304
Name:PETERS, KEVIN PATRICK (PA-C)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:PATRICK
Last Name:PETERS
Suffix:
Gender:
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 1:4309 W MEDICAL CENTER DR STE A200
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-8437
Mailing Address - Country:US
Mailing Address - Phone:815-759-8070
Mailing Address - Fax:815-759-4931
Practice Address - Street 1:4309 W MEDICAL CENTER DR STE A200
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-8437
Practice Address - Country:US
Practice Address - Phone:815-759-8070
Practice Address - Fax:815-759-4931
Is Sole Proprietor?:No
Enumeration Date:2018-07-23
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID2280363AS0400X
IL085006652363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical