Provider Demographics
NPI:1801410451
Name:LILLIE, KATE (PA-C)
Entity Type:Individual
Prefix:
First Name:KATE
Middle Name:
Last Name:LILLIE
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 1:3015 NE OVERLOOK DR APT 735
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-7204
Mailing Address - Country:US
Mailing Address - Phone:907-406-8310
Mailing Address - Fax:
Practice Address - Street 1:660 S 200 E STE 250
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-3846
Practice Address - Country:US
Practice Address - Phone:801-359-2256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-29
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12993974-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant