Provider Demographics
NPI:1013351964
Name:CANDEE, KATINA M (PA-C)
Entity Type:Individual
Prefix:
First Name:KATINA
Middle Name:M
Last Name:CANDEE
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:PO BOX 890700
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92589-0700
Mailing Address - Country:US
Mailing Address - Phone:951-233-6205
Mailing Address - Fax:
Practice Address - Street 1:621 S NEW BALLAS RD
Practice Address - Street 2:SUITE 483A
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8232
Practice Address - Country:US
Practice Address - Phone:314-251-2095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-23
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22905363A00000X
UT8547052-1206363A00000X
MO2013032509363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant