Provider Demographics
NPI:1124229612
Name:EVERHART, KATHLENE MARIE (PA)
Entity Type:Individual
Prefix:MRS
First Name:KATHLENE
Middle Name:MARIE
Last Name:EVERHART
Suffix:
Gender:F
Credentials:PA
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 7849
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92513-7849
Mailing Address - Country:US
Mailing Address - Phone:951-358-5222
Mailing Address - Fax:951-358-5235
Practice Address - Street 1:9415 MISSION BLVD
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92509-2600
Practice Address - Country:US
Practice Address - Phone:951-360-8795
Practice Address - Fax:951-360-8798
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA18713363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAME1525154OtherDEA