Provider Demographics
NPI:1386718278
Name:ROGOWSKI, KATHLEEN T (PA-C)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:T
Last Name:ROGOWSKI
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 1:1051 W US ROUTE 6
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-3349
Mailing Address - Country:US
Mailing Address - Phone:815-942-4875
Mailing Address - Fax:815-942-5046
Practice Address - Street 1:1051 W US ROUTE 6
Practice Address - Street 2:SUITE 100
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450-3349
Practice Address - Country:US
Practice Address - Phone:815-942-4875
Practice Address - Fax:815-942-5046
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-002737363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085-002737OtherSTATE LICENSE
ILK53347Medicare PIN
IL370830012Medicare PIN
IL085-002737OtherSTATE LICENSE
208592Medicare UPIN
208887Medicare UPIN
ILP00704592Medicare PIN