Provider Demographics
NPI:1417702036
Name:TA, KATIE (DO)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:TA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8627 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH GATE
Mailing Address - State:CA
Mailing Address - Zip Code:90280-3501
Mailing Address - Country:US
Mailing Address - Phone:323-312-2605
Mailing Address - Fax:
Practice Address - Street 1:8627 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:SOUTH GATE
Practice Address - State:CA
Practice Address - Zip Code:90280-3501
Practice Address - Country:US
Practice Address - Phone:323-312-2605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-18
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program