Provider Demographics
NPI:1639110786
Name:LOVE, KATHERINE ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ANN
Last Name:LOVE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:ANNE
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:825 BENNETT AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504
Mailing Address - Country:US
Mailing Address - Phone:541-779-5228
Mailing Address - Fax:541-772-1533
Practice Address - Street 1:825 BENNETT AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504
Practice Address - Country:US
Practice Address - Phone:541-779-5228
Practice Address - Fax:541-772-1533
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003940363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S97624Medicare UPIN