Provider Demographics
NPI:1770584070
Name:FERNAN, KATHLEEN M (DO)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:FERNAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 SOUTH MILL STREET
Mailing Address - Street 2:
Mailing Address - City:RIDGWAY
Mailing Address - State:PA
Mailing Address - Zip Code:15853
Mailing Address - Country:US
Mailing Address - Phone:814-772-0722
Mailing Address - Fax:814-772-6934
Practice Address - Street 1:200 SOUTH MILL STREET
Practice Address - Street 2:
Practice Address - City:RIDGWAY
Practice Address - State:PA
Practice Address - Zip Code:15853
Practice Address - Country:US
Practice Address - Phone:814-772-0722
Practice Address - Fax:814-772-6934
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS013170207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1016386070001Medicaid
PA1016386070002Medicaid
PA1833904OtherHIGHMARK
PA089672Medicare ID - Type Unspecified
PAI27829Medicare UPIN