Provider Demographics
NPI:1033119482
Name:GOTWALS, KATHLEEN MANTZ (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MANTZ
Last Name:GOTWALS
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 216
Mailing Address - Street 2:
Mailing Address - City:PENNSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18073-0216
Mailing Address - Country:US
Mailing Address - Phone:215-679-8071
Mailing Address - Fax:215-541-4171
Practice Address - Street 1:2781 GERYVILLE PIKE
Practice Address - Street 2:
Practice Address - City:PENNSBURG
Practice Address - State:PA
Practice Address - Zip Code:18073-2306
Practice Address - Country:US
Practice Address - Phone:215-679-8071
Practice Address - Fax:215-541-4171
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA002439L363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP60426Medicare UPIN