Provider Demographics
NPI:1922217751
Name:EWALL, KATHARINE
Entity Type:Individual
Prefix:
First Name:KATHARINE
Middle Name:
Last Name:EWALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:NORTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01060-2052
Mailing Address - Country:US
Mailing Address - Phone:413-582-2792
Mailing Address - Fax:413-582-4675
Practice Address - Street 1:30 LOCUST ST
Practice Address - Street 2:
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01060-2052
Practice Address - Country:US
Practice Address - Phone:413-582-2792
Practice Address - Fax:413-582-4675
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA247001207R00000X, 208000000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ400330656Medicare UPIN