Provider Demographics
NPI:1780095638
Name:KHORSAND, KATE (MD)
Entity type:Individual
Prefix:DR
First Name:KATE
Middle Name:
Last Name:KHORSAND
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATE
Other - Middle Name:
Other - Last Name:BUCKLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2003 KOOTENAI HEALTH WAY
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-6051
Mailing Address - Country:US
Mailing Address - Phone:208-625-4333
Mailing Address - Fax:208-625-4334
Practice Address - Street 1:980 W IRONWOOD DR STE 1
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2617
Practice Address - Country:US
Practice Address - Phone:208-625-4333
Practice Address - Fax:208-625-4334
Is Sole Proprietor?:No
Enumeration Date:2014-05-14
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM15032207N00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program