Provider Demographics
NPI:1619029451
Name:BOSTRON, KATRINA ANDERSON (PT)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:ANDERSON
Last Name:BOSTRON
Suffix:
Gender:F
Credentials:PT
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 803
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:KY
Mailing Address - Zip Code:41339-0803
Mailing Address - Country:US
Mailing Address - Phone:606-666-9293
Mailing Address - Fax:606-666-9220
Practice Address - Street 1:695 KY HWY 15N
Practice Address - Street 2:SUITE 3
Practice Address - City:JACKSON
Practice Address - State:KY
Practice Address - Zip Code:41339
Practice Address - Country:US
Practice Address - Phone:606-666-9293
Practice Address - Fax:606-666-9220
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2009-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY002877225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP02898Medicare UPIN
KY5026701Medicare PIN