Provider Demographics
NPI:1487641288
Name:IVERSON, KATIE C (PA)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:C
Last Name:IVERSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:L
Other - Last Name:COOK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:5167 WESTLAWN
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1100
Mailing Address - Country:US
Mailing Address - Phone:319-353-5388
Mailing Address - Fax:
Practice Address - Street 1:502 N 9TH AVE
Practice Address - Street 2:
Practice Address - City:VINTON
Practice Address - State:IA
Practice Address - Zip Code:52349-2254
Practice Address - Country:US
Practice Address - Phone:319-472-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001583363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA03137OtherWELLMARK BCBS
IA03137OtherWELLMARK BCBS
IAI20383Medicare PIN