Provider Demographics
NPI:1619370871
Name:DOERKSEN, KATHRYN ANNE (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ANNE
Last Name:DOERKSEN
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 1:1800 N CALIFORNIA ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-6019
Mailing Address - Country:US
Mailing Address - Phone:209-467-6560
Mailing Address - Fax:
Practice Address - Street 1:1800 N CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204
Practice Address - Country:US
Practice Address - Phone:209-467-6560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-02
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52976363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX343266801 (MDACC)Medicaid
TX343266801 (MDACC)Medicaid