Provider Demographics
NPI:1538139688
Name:HODGES, KATHLEEN M (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:M
Last Name:HODGES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5100 GATEWAY CTR
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-3927
Mailing Address - Country:US
Mailing Address - Phone:810-733-6480
Mailing Address - Fax:810-733-6483
Practice Address - Street 1:5100 GATEWAY CTR
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-3927
Practice Address - Country:US
Practice Address - Phone:810-733-6480
Practice Address - Fax:810-733-6483
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003515363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP32715Medicare UPIN
N87110015Medicare PIN