Provider Demographics
NPI:1740358167
Name:VAN ATTA, KATHERINE GRACE (PA-C, CNM)
Entity type:Individual
Prefix:MS
First Name:KATHERINE
Middle Name:GRACE
Last Name:VAN ATTA
Suffix:
Gender:F
Credentials:PA-C, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 E SHENNUM DR
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7718
Mailing Address - Country:US
Mailing Address - Phone:907-373-3420
Mailing Address - Fax:907-376-7847
Practice Address - Street 1:5000 E SHENNUM DR
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7718
Practice Address - Country:US
Practice Address - Phone:907-373-3420
Practice Address - Fax:907-376-7847
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK879363A00000X
367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMDA0205Medicaid