Healthcare Provider Details

I. General information

NPI: 1437738242
Provider Name (Legal Business Name): KAITLYN ROSE PATACCA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2021
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1840 MESQUITE AVE STE A
LAKE HAVASU CITY AZ
86403-5771
US

IV. Provider business mailing address

1840 MESQUITE AVE STE A
LAKE HAVASU CITY AZ
86403-5771
US

V. Phone/Fax

Practice location:
  • Phone: 928-855-8185
  • Fax:
Mailing address:
  • Phone: 928-854-0069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number80301
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: