Provider Demographics
NPI:1992072649
Name:DOLDER, KRISTEN L (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:L
Last Name:DOLDER
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 1:1340 RYAN PKWY
Mailing Address - Street 2:
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102-4527
Mailing Address - Country:US
Mailing Address - Phone:815-276-0150
Mailing Address - Fax:877-461-6742
Practice Address - Street 1:1340 RYAN PKWY
Practice Address - Street 2:
Practice Address - City:ALGONQUIN
Practice Address - State:IL
Practice Address - Zip Code:60102-4527
Practice Address - Country:US
Practice Address - Phone:815-276-0150
Practice Address - Fax:877-461-6742
Is Sole Proprietor?:No
Enumeration Date:2011-11-23
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004109363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085004109OtherLICENSE
ILF400098795Medicare PIN
IL213921003Medicare PIN