Provider Demographics
NPI:1801096268
Name:EBERLY, KATHERINE MARIE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:MARIE
Last Name:EBERLY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:MARIE
Other - Last Name:JAMES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:12469 EMERALD COAST PKWY W
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MIRAMAR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32550-8305
Mailing Address - Country:US
Mailing Address - Phone:850-654-3376
Mailing Address - Fax:850-654-3320
Practice Address - Street 1:12469 EMERALD COAST PKWY W
Practice Address - Street 2:SUITE 101
Practice Address - City:MIRAMAR BEACH
Practice Address - State:FL
Practice Address - Zip Code:32550-8305
Practice Address - Country:US
Practice Address - Phone:850-654-3376
Practice Address - Fax:850-654-3320
Is Sole Proprietor?:No
Enumeration Date:2007-07-23
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104814363A00000X
GA005091363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY05LXOtherBC OF FL