Provider Demographics
NPI:1215371307
Name:PAVLIK, KATHERINE NELSON
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:NELSON
Last Name:PAVLIK
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 1:1000 S FREMONT AVE
Mailing Address - Street 2:UNIT 7, BLDG A11, ROOM 11158
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91803-8800
Mailing Address - Country:US
Mailing Address - Phone:859-321-4516
Mailing Address - Fax:
Practice Address - Street 1:1000 S FREMONT AVE
Practice Address - Street 2:UNIT 7, BLDG A11, ROOM 11158
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91803-8800
Practice Address - Country:US
Practice Address - Phone:859-321-4516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-19
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA23042363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant