Provider Demographics
NPI:1740337237
Name:HERREN, KATHY A (PA-C)
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:A
Last Name:HERREN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATHY
Other - Middle Name:A
Other - Last Name:HENRY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3412 OFFICE PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959
Mailing Address - Country:US
Mailing Address - Phone:618-993-0404
Mailing Address - Fax:618-993-1717
Practice Address - Street 1:3412 OFFICE PARK DRIVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959
Practice Address - Country:US
Practice Address - Phone:618-993-0404
Practice Address - Fax:618-993-1717
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002634363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL080129117OtherRAILROAD MEDICARE
IL174143OtherHEALTHLINK
IL10019630OtherBLUE CROSS
ILE26544OtherUPIN
IL143870Medicaid
IL043448OtherHEALTH ALLIANCE