Provider Demographics
NPI:1508109844
Name:ZAGAMI, KAITLIN MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:MARIE
Last Name:ZAGAMI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KAITLIN
Other - Middle Name:M
Other - Last Name:KEAVENY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:3999 DUTCHMANS LN STE 6F
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4724
Practice Address - Country:US
Practice Address - Phone:502-394-5678
Practice Address - Fax:502-394-5600
Is Sole Proprietor?:No
Enumeration Date:2013-04-05
Last Update Date:2020-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA1796363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100248600Medicaid
KY7100248600Medicaid