Healthcare Provider Details

I. General information

NPI: 1508064593
Provider Name (Legal Business Name): KATHERINE JANE BERMAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2007
Last Update Date: 01/03/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

283 MADONNA RD
SAN LUIS OBISPO CA
93405-5432
US

IV. Provider business mailing address

166 LOMA BONITA DR
SAN LUIS OBISPO CA
93401-6629
US

V. Phone/Fax

Practice location:
  • Phone: 805-549-8880
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA00443
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA053051
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA22010
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: