Provider Demographics
NPI:1073715009
Name:PHILLIPS, CATHERINE MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:CATHERINE
Middle Name:MARIE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CATHERINE
Other - Middle Name:MARIE
Other - Last Name:TRIMBLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:46637 465TH LN
Mailing Address - Street 2:PO BOX 112
Mailing Address - City:GLENCOE
Mailing Address - State:MN
Mailing Address - Zip Code:55336-5269
Mailing Address - Country:US
Mailing Address - Phone:320-864-3491
Mailing Address - Fax:
Practice Address - Street 1:1230 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-5066
Practice Address - Country:US
Practice Address - Phone:507-625-1811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9231363A00000X
WAPA10003181363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP30365Medicare UPIN