Provider Demographics
NPI:1346843695
Name:DOUGHERTY, KATHRYN (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:DOUGHERTY
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 1:229 E BEECHTREE LN
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:PA
Mailing Address - Zip Code:19087-3436
Mailing Address - Country:US
Mailing Address - Phone:484-802-7003
Mailing Address - Fax:
Practice Address - Street 1:4190 CITY AVE STE 528
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-1635
Practice Address - Country:US
Practice Address - Phone:866-453-8800
Practice Address - Fax:844-734-7689
Is Sole Proprietor?:No
Enumeration Date:2020-11-19
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA061924363A00000X
DCCA210001370363A00000X
PAOA005376363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant