Provider Demographics
NPI:1265002141
Name:WENTWORTH, KATHERINE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KATHERINE
Middle Name:
Last Name:WENTWORTH
Suffix:
Gender:F
Credentials:PA-C
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 679706
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-9706
Mailing Address - Country:US
Mailing Address - Phone:512-792-4402
Mailing Address - Fax:512-792-4420
Practice Address - Street 1:1900 SCENIC DR STE 2220
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-7703
Practice Address - Country:US
Practice Address - Phone:512-819-0132
Practice Address - Fax:512-819-9335
Is Sole Proprietor?:No
Enumeration Date:2021-07-01
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA14249363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant