Provider Demographics
NPI:1598231623
Name:MONDADA, KATHERINE LINDSAY (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:LINDSAY
Last Name:MONDADA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:LINDSAY
Other - Last Name:MONDADA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 749495
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-9495
Mailing Address - Country:US
Mailing Address - Phone:239-432-8331
Mailing Address - Fax:813-321-1296
Practice Address - Street 1:2855 E MAGIC VIEW DR STE B
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6245
Practice Address - Country:US
Practice Address - Phone:208-888-8209
Practice Address - Fax:208-888-8211
Is Sole Proprietor?:No
Enumeration Date:2018-10-16
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA61091674363A00000X
IDPA-1658363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant