Provider Demographics
NPI:1194018754
Name:CODY, KATHLEEN M (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:CODY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:KIA
Other - Middle Name:M
Other - Last Name:CODY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:2625 E DIVISADERO ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93721-1431
Mailing Address - Country:US
Mailing Address - Phone:559-443-2682
Mailing Address - Fax:559-443-2681
Practice Address - Street 1:2823 FRESNO ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93721-1324
Practice Address - Country:US
Practice Address - Phone:559-459-3770
Practice Address - Fax:559-459-3719
Is Sole Proprietor?:No
Enumeration Date:2011-05-16
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21246363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant