Provider Demographics
NPI:1164530069
Name:THATCHER, KATHRYN ANN
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ANN
Last Name:THATCHER
Suffix:
Gender:F
Credentials:
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 8043
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30460-8043
Mailing Address - Country:US
Mailing Address - Phone:912-478-5641
Mailing Address - Fax:
Practice Address - Street 1:4002 FOREST DR
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30460-0001
Practice Address - Country:US
Practice Address - Phone:912-478-5641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004559363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA161445499AMedicaid
GA161445499AMedicaid