Provider Demographics
NPI:1740230077
Name:ERVIE, KATHERINE GALE (PAC)
Entity type:Individual
Prefix:MS
First Name:KATHERINE
Middle Name:GALE
Last Name:ERVIE
Suffix:
Gender:
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1706 PROSPECT DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:MO
Mailing Address - Zip Code:63552-2615
Mailing Address - Country:US
Mailing Address - Phone:660-385-1006
Mailing Address - Fax:660-890-8422
Practice Address - Street 1:1706 PROSPECT DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:MO
Practice Address - Zip Code:63552-2615
Practice Address - Country:US
Practice Address - Phone:660-385-1006
Practice Address - Fax:660-890-8422
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO114815363AS0400X
MODA114815363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
248A239Medicare ID - Type Unspecified
S72445Medicare UPIN