Provider Demographics
NPI:1417148743
Name:MATTERN, KATHERINE LYNN (PA)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:LYNN
Last Name:MATTERN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:650 S COURTENAY PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32952-4977
Mailing Address - Country:US
Mailing Address - Phone:321-394-2660
Mailing Address - Fax:321-394-2669
Practice Address - Street 1:650 S COURTENAY PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952-4977
Practice Address - Country:US
Practice Address - Phone:321-394-2660
Practice Address - Fax:321-394-2669
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106262363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLNS448OtherFL MEDICARE
NC202014OtherMEDCOST
9772073OtherAETNA