Provider Demographics
NPI:1093575813
Name:TUPPER, KATHERINE JO (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:JO
Last Name:TUPPER
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 1:2430 FAYETTE AVE
Mailing Address - Street 2:
Mailing Address - City:IONIA
Mailing Address - State:IA
Mailing Address - Zip Code:50645-9576
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:350 NE 36TH ST
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50021-6728
Practice Address - Country:US
Practice Address - Phone:515-224-1414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-20
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
IA123676363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant