Provider Demographics
NPI:1861687709
Name:BORTNER, KATHERINE BETH (PA)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:BETH
Last Name:BORTNER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:B
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1803 MOUNT ROSE AVE
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17403-3026
Mailing Address - Country:US
Mailing Address - Phone:717-851-1405
Mailing Address - Fax:717-851-1665
Practice Address - Street 1:25 MONUMENT RD
Practice Address - Street 2:SUITE 190
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-5060
Practice Address - Country:US
Practice Address - Phone:717-851-6454
Practice Address - Fax:717-851-1665
Is Sole Proprietor?:No
Enumeration Date:2007-09-13
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA053232363A00000X
PATMA051810363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2606530OtherHIGHMARK BLUE SHIELD-WMG
PA1593951OtherGATEWAY-WMG
PA1593951OtherGATEWAY-WMG