Provider Demographics
NPI:1588052385
Name:DERUNGS, KRISTIN M (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:M
Last Name:DERUNGS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:M
Other - Last Name:DILEONARDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:17495 LA GRANGE RD
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60487-7581
Mailing Address - Country:US
Mailing Address - Phone:708-226-7000
Mailing Address - Fax:708-226-7174
Practice Address - Street 1:17495 LA GRANGE RD
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60487-7581
Practice Address - Country:US
Practice Address - Phone:708-226-7000
Practice Address - Fax:708-226-7174
Is Sole Proprietor?:No
Enumeration Date:2014-12-31
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085005320363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400191117OtherLOCALITY 16
ILP01445054OtherRRMC
ILF400191119OtherLOCALITY 15
ILF400191119OtherLOCALITY 15
ILF400191119Medicare PIN
ILF400191117Medicare PIN