Provider Demographics
NPI:1578814414
Name:TRIPP, KATRINA L (PAC)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:L
Last Name:TRIPP
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:KATRINA
Other - Middle Name:L
Other - Last Name:HOLCOMB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:PO BOX 155
Mailing Address - Street 2:
Mailing Address - City:CHRISTOPHER
Mailing Address - State:IL
Mailing Address - Zip Code:62822-0155
Mailing Address - Country:US
Mailing Address - Phone:618-724-2401
Mailing Address - Fax:618-724-4628
Practice Address - Street 1:7211 US 45 S
Practice Address - Street 2:
Practice Address - City:CARRIER MILLS
Practice Address - State:IL
Practice Address - Zip Code:62917-1305
Practice Address - Country:US
Practice Address - Phone:618-209-0498
Practice Address - Fax:618-724-4628
Is Sole Proprietor?:No
Enumeration Date:2012-10-01
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004472363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214881Medicare Oscar/Certification