Provider Demographics
NPI:1689913410
Name:KATHAWA, HEATHER M (PAC)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:M
Last Name:KATHAWA
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 BROOKVIEW CENTRE WAY
Mailing Address - Street 2:SUITE 400
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37919-4049
Mailing Address - Country:US
Mailing Address - Phone:800-342-2898
Mailing Address - Fax:
Practice Address - Street 1:18101 OAKWOOD BLVD
Practice Address - Street 2:EMERGENCY DEPT
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-4089
Practice Address - Country:US
Practice Address - Phone:313-593-8780
Practice Address - Fax:313-436-2864
Is Sole Proprietor?:No
Enumeration Date:2013-02-14
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601006579363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI12501261OtherCAQH