Provider Demographics
NPI:1932418738
Name:LANSBURG, KATHERINE M (MS PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:M
Last Name:LANSBURG
Suffix:
Gender:F
Credentials:MS PA-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4572 S CRUZATTE LN
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83716-5611
Mailing Address - Country:US
Mailing Address - Phone:714-290-5841
Mailing Address - Fax:
Practice Address - Street 1:1520 W STATE ST STE 100
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4084
Practice Address - Country:US
Practice Address - Phone:208-947-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-28
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21172363AM0700X
IDPA-2088363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical