Provider Demographics
NPI:1578089769
Name:DEZUTTER, KATHERINE (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:DEZUTTER
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 1:819 WORCESTER ST STE 1
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01151-1056
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:819 WORCESTER ST STE 1
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01151-1056
Practice Address - Country:US
Practice Address - Phone:413-304-2501
Practice Address - Fax:413-789-0290
Is Sole Proprietor?:No
Enumeration Date:2017-08-18
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X, 390200000X
MAPA7967363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program