Provider Demographics
NPI:1801194972
Name:BLACK, KATRINA D (PA)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:D
Last Name:BLACK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KATRINA
Other - Middle Name:D
Other - Last Name:BROOMFIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10800 BRIGHTON BAY BLVD NE APT 3104
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33716-3490
Mailing Address - Country:US
Mailing Address - Phone:912-292-7116
Mailing Address - Fax:
Practice Address - Street 1:3345 S DALE MABRY HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-7817
Practice Address - Country:US
Practice Address - Phone:813-234-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-14
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004612363AM0700X
FLPA9110311363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical