Healthcare Provider Details

I. General information

NPI: 1871770776
Provider Name (Legal Business Name): CATHERINE J KOTALIK PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2008
Last Update Date: 10/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 S GOVERNORS AVE SUITE 100
DOVER DE
19904-3530
US

IV. Provider business mailing address

640 S STATE ST ADMINISTRATION -742 BLDG
DOVER DE
19901-3530
US

V. Phone/Fax

Practice location:
  • Phone: 302-526-1470
  • Fax: 302-674-1398
Mailing address:
  • Phone: 302-674-3970
  • Fax: 302-672-2350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number001883
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC5-0000763
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: