Provider Demographics
NPI:1275937898
Name:FERGUSON, KAITLYN (PA-C)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:FERGUSON
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 1:2315 MYRTLE ST STE L90
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16502-4607
Mailing Address - Country:US
Mailing Address - Phone:814-452-7575
Mailing Address - Fax:
Practice Address - Street 1:2315 MYRTLE ST STE L90
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16502-4607
Practice Address - Country:US
Practice Address - Phone:814-452-7575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-09
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA058740363AM0700X
OH50.004158363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical