Provider Demographics
NPI:1982217147
Name:STEARNS, KATELYN (PA-C)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:STEARNS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3765 E. BLUE LUPINE DR. SUITE D
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654
Mailing Address - Country:US
Mailing Address - Phone:907-707-1671
Mailing Address - Fax:
Practice Address - Street 1:3765 E. BLUE LUPINE DR. STE D
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654
Practice Address - Country:US
Practice Address - Phone:907-707-1671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-27
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X, 363A00000X
AK184340363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1725360Medicaid