Provider Demographics
NPI:1962010298
Name:CLINKENBEARD, KATHERINE D (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:D
Last Name:CLINKENBEARD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:A
Other - Last Name:DULIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:3200 E CAMELBACK RD STE 250
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-2327
Mailing Address - Country:US
Mailing Address - Phone:602-933-1813
Mailing Address - Fax:
Practice Address - Street 1:1919 E THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7710
Practice Address - Country:US
Practice Address - Phone:602-933-0016
Practice Address - Fax:602-933-4318
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-22
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7985363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ086583Medicaid