Provider Demographics
NPI:1912538562
Name:DERR, KATHLEEN SARAH (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:SARAH
Last Name:DERR
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:SARAH
Other - Last Name:HITT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 PRESTIGE PL STE 550
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-6115
Mailing Address - Country:US
Mailing Address - Phone:937-762-1310
Mailing Address - Fax:937-522-8068
Practice Address - Street 1:425 W GRAND AVE STE 2002
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45405-4722
Practice Address - Country:US
Practice Address - Phone:937-425-4144
Practice Address - Fax:937-425-4146
Is Sole Proprietor?:No
Enumeration Date:2020-02-03
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.006351RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant