Provider Demographics
NPI:1073826079
Name:FOSTER, KATHERINE G (PA)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:G
Last Name:FOSTER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:G
Other - Last Name:TACKES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:8170 33RD AVE S # MS 21110Q
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2500 COMO AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55108-1460
Practice Address - Country:US
Practice Address - Phone:651-641-6200
Practice Address - Fax:651-641-6295
Is Sole Proprietor?:No
Enumeration Date:2010-07-19
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10854363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1073826079Medicaid
MN970005573Medicare PIN