Basic Information
| Provider Information | |||||||||
| NPI: | 1104813849 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WRIGHT | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4300 COMMERCE CT | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | LISLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605323698 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309681881 | ||||||||
| FaxNumber: | 6302459098 | ||||||||
| Practice Location | |||||||||
| Address1: | 1259 RICKERT DR | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | NAPERVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605408902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6303551300 | ||||||||
| FaxNumber: | 6303553273 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2005 | ||||||||
| LastUpdateDate: | 03/04/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 085002508 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | 085002508 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | P00297120 | 01 | IL | RAILROAD MEDICARE | OTHER | 085002508 | 05 | IL | MEDICAID |