Provider Demographics
NPI:1568481869
Name:KATAVICH, LUCILLE (PA-C)
Entity Type:Individual
Prefix:
First Name:LUCILLE
Middle Name:
Last Name:KATAVICH
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 1:5420 QUAIL VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-8615
Mailing Address - Country:US
Mailing Address - Phone:530-677-9702
Mailing Address - Fax:
Practice Address - Street 1:6600 MERCY CT STE 110
Practice Address - Street 2:
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-3150
Practice Address - Country:US
Practice Address - Phone:916-966-5404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA10091363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical