Provider Demographics
NPI:1760141493
Name:TASSON, KATHRYN (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:TASSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:
Other - Last Name:ETELAMAKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:815 N CLARE AVE STE A
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:MI
Mailing Address - Zip Code:48625-8177
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:815 N CLARE AVE STE A
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:MI
Practice Address - Zip Code:48625-8177
Practice Address - Country:US
Practice Address - Phone:989-539-4434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-09
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601011315363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant