Provider Demographics
NPI: | 1417288325 |
---|---|
Name: | CALHOUN, KATHRYN E (PA-C) |
Entity Type: | Individual |
Prefix: | |
First Name: | KATHRYN |
Middle Name: | E |
Last Name: | CALHOUN |
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: | 2817 REILLY ST |
Mailing Address - Street 2: | |
Mailing Address - City: | FORT BRAGG |
Mailing Address - State: | NC |
Mailing Address - Zip Code: | 28310-7324 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 910-907-2778 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 2817 REILLY ST |
Practice Address - Street 2: | |
Practice Address - City: | FORT BRAGG |
Practice Address - State: | NC |
Practice Address - Zip Code: | 28310-7324 |
Practice Address - Country: | US |
Practice Address - Phone: | 910-907-2778 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2010-01-18 |
Last Update Date: | 2022-03-01 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
PA | OA002432 | 363AM0700X |
PA | MA54269 | 363AM0700X |
NC | 0010-11127 | 363A00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | |
No | 363AM0700X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
12078131 | Other | CAQH | |
NY | 05032086 | Medicaid |