Provider Demographics
NPI:1588630826
Name:KNUTSON, KATHERYN (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHERYN
Middle Name:
Last Name:KNUTSON
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-3292
Mailing Address - Fax:239-343-3695
Practice Address - Street 1:2776 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-5864
Practice Address - Country:US
Practice Address - Phone:239-343-2606
Practice Address - Fax:239-343-3695
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA0003657363AS0400X
FLPA3657363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00940418OtherRAILROAD MCR
FLP01806155OtherCLEAR HEALTH
FL239084OtherUNIVERSAL HEALTHCARE
FL290439000Medicaid
FL9135706OtherAETNA
FL250699OtherAVMED
FLP933593OtherOPTIMUM
FLY06VSOtherBCBS FL
FLY06VSOtherBCBS
FL9081147OtherCIGNA
FLP01753553OtherRR MEDICARE
FLP113815OtherFREEDOM HEALTH
FLP01806155OtherCLEAR HEALTH
FL9081147OtherCIGNA
FLS67768Medicare UPIN
FL290439000Medicaid