Provider Demographics
NPI:1528040052
Name:LAKE, CATHERINE ANN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:CATHERINE
Middle Name:ANN
Last Name:LAKE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:LAURIE
Other - Middle Name:ANN
Other - Last Name:DICKINSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:847 W CHILDS AVE
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95341-6862
Mailing Address - Country:US
Mailing Address - Phone:209-383-7441
Mailing Address - Fax:209-383-1643
Practice Address - Street 1:737 W CHILDS AVE
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95341-6805
Practice Address - Country:US
Practice Address - Phone:209-383-1848
Practice Address - Fax:209-383-1296
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13544363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMD1300196OtherDEA CERT#
CAMD1300196OtherDEA CERT#