Provider Demographics
NPI:1609128990
Name:ANDERSON, KATHERINE L (P A)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:L
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:P A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3015 SQUALICUM PKWY STE 180
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-1946
Mailing Address - Country:US
Mailing Address - Phone:360-733-5733
Mailing Address - Fax:360-733-1859
Practice Address - Street 1:3015 SQUALICUM PKWY STE 180
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-1946
Practice Address - Country:US
Practice Address - Phone:360-733-5733
Practice Address - Fax:360-733-1859
Is Sole Proprietor?:No
Enumeration Date:2012-10-10
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2012-0047363A00000X
363AM0700X
WAPA60892445363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2125322Medicaid