Healthcare Provider Details

I. General information

NPI: 1407768476
Provider Name (Legal Business Name): KATHERINE LY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79215 CORPORATE CENTER DR STE 120
LA QUINTA CA
92253-7232
US

IV. Provider business mailing address

79215 CORPORATE CENTER DR STE 120
LA QUINTA CA
92253-7232
US

V. Phone/Fax

Practice location:
  • Phone: 760-771-1111
  • Fax:
Mailing address:
  • Phone: 760-771-1111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA68722
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: