Provider Demographics
NPI:1679862833
Name:FERGUSON, KATHLEEN
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2113 E MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78702-1357
Mailing Address - Country:US
Mailing Address - Phone:512-391-9700
Mailing Address - Fax:512-391-9703
Practice Address - Street 1:2113 E MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78702-1357
Practice Address - Country:US
Practice Address - Phone:512-391-9700
Practice Address - Fax:512-391-9703
Is Sole Proprietor?:No
Enumeration Date:2011-03-28
Last Update Date:2011-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX760886364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health