Healthcare Provider Details

I. General information

NPI: 1750734604
Provider Name (Legal Business Name): KATHRYN DIANNE HERDEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2016
Last Update Date: 02/28/2020
Certification Date: 02/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7560 RED BUG LAKE RD STE 2048
OVIEDO FL
32765-6591
US

IV. Provider business mailing address

7560 RED BUG LAKE RD STE 2048
OVIEDO FL
32765-6591
US

V. Phone/Fax

Practice location:
  • Phone: 407-366-8856
  • Fax: 407-977-4319
Mailing address:
  • Phone: 407-366-8856
  • Fax: 407-977-4319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9110990
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: