Provider Demographics
NPI:1851696843
Name:CHILDRESS, CATHY SUE (PA)
Entity Type:Individual
Prefix:
First Name:CATHY
Middle Name:SUE
Last Name:CHILDRESS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 550
Mailing Address - Street 2:302 SOUTH 1ST AVENUE
Mailing Address - City:MARTIN
Mailing Address - State:SD
Mailing Address - Zip Code:57551-0550
Mailing Address - Country:US
Mailing Address - Phone:605-685-6868
Mailing Address - Fax:605-685-6943
Practice Address - Street 1:302 SOUTH 1ST AVENUE
Practice Address - Street 2:
Practice Address - City:MARTIN
Practice Address - State:SD
Practice Address - Zip Code:57551
Practice Address - Country:US
Practice Address - Phone:605-685-6868
Practice Address - Fax:605-685-6943
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-21
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SD0766363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant