Provider Demographics
NPI:1003806993
Name:WARREN, KATHRYN JEAN (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:KATHRYN
Middle Name:JEAN
Last Name:WARREN
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:PO BOX 918025
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-8025
Mailing Address - Country:US
Mailing Address - Phone:352-273-7832
Mailing Address - Fax:352-392-8530
Practice Address - Street 1:2000 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-1136
Practice Address - Country:US
Practice Address - Phone:352-265-0725
Practice Address - Fax:352-265-8432
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL14551982255A2300X
FLPA 9105043363A00000X
FLPA9105043363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT204Medicare PIN