Provider Demographics
NPI:1003683509
Name:CLARK, KATHERINE ROSE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:ROSE
Last Name:CLARK
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:MS
Other - First Name:KATHERINE
Other - Middle Name:ROSE
Other - Last Name:MATTINEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:5109 36TH AVE N
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55422
Mailing Address - Country:US
Mailing Address - Phone:763-587-7999
Mailing Address - Fax:763-587-7989
Practice Address - Street 1:5109 36TH AVE N
Practice Address - Street 2:
Practice Address - City:CRYSTAL
Practice Address - State:MN
Practice Address - Zip Code:55422
Practice Address - Country:US
Practice Address - Phone:763-587-7999
Practice Address - Fax:763-587-7989
Is Sole Proprietor?:No
Enumeration Date:2023-12-05
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN14744363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant