Provider Demographics
NPI:1427000702
Name:PRENDERGAST, KATHRYN L (PA)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:L
Last Name:PRENDERGAST
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4750 HEMPSTEAD STATION DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-5164
Mailing Address - Country:US
Mailing Address - Phone:800-875-0136
Mailing Address - Fax:937-619-4231
Practice Address - Street 1:1343 N FOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45504-1422
Practice Address - Country:US
Practice Address - Phone:937-390-5000
Practice Address - Fax:937-390-5526
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50000711363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00034017OtherRAIL ROAD MEDICARE
PRPA10626Medicare PIN
S86904Medicare UPIN
OHPRPA10629Medicare PIN
PRPA10627Medicare PIN