Provider Demographics
NPI:1770863862
Name:HADLOCK, KATHERINE MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:MARIE
Last Name:HADLOCK
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 1:585 N 500 W
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-1548
Mailing Address - Country:US
Mailing Address - Phone:801-374-1801
Mailing Address - Fax:801-216-8357
Practice Address - Street 1:819 E MARKET PLACE DR 3RD FLOOR
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660-8466
Practice Address - Country:US
Practice Address - Phone:801-374-1801
Practice Address - Fax:801-216-8357
Is Sole Proprietor?:No
Enumeration Date:2011-08-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT80464531206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT80464531206OtherLICENSE
NMPA2018-0052OtherLICENSE
UT80464531206OtherLICENSE
UTMA2426751OtherDEA