Healthcare Provider Details

I. General information

NPI: 1619703709
Provider Name (Legal Business Name): KATHERINE KOLIGIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2024
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8635 W 3RD ST STE 990W
LOS ANGELES CA
90048-6116
US

IV. Provider business mailing address

8223 BLACKBURN AVE APT 205
LOS ANGELES CA
90048-4276
US

V. Phone/Fax

Practice location:
  • Phone: 310-423-5900
  • Fax:
Mailing address:
  • Phone: 559-930-5083
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number67107
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: