Provider Demographics
NPI:1194844183
Name:GRESHAM, KATHERINE MARY (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:KATHERINE
Middle Name:MARY
Last Name:GRESHAM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2248 W GERMANTOWN SQ
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-4814
Mailing Address - Country:US
Mailing Address - Phone:901-756-7492
Mailing Address - Fax:
Practice Address - Street 1:7485 POPLAR PIKE
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-5934
Practice Address - Country:US
Practice Address - Phone:901-752-4999
Practice Address - Fax:901-752-3761
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2009-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1337363A00000X
FLPA9103353363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant