Healthcare Provider Details

I. General information

NPI: 1780095638
Provider Name (Legal Business Name): KATE KHORSAND M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATE BUCKLEY

II. Dates (important events)

Enumeration Date: 05/14/2014
Last Update Date: 11/16/2020
Certification Date: 11/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 W IRONWOOD DR STE 1
COEUR D ALENE ID
83814-2617
US

IV. Provider business mailing address

2003 KOOTENAI HEALTH WAY
COEUR D ALENE ID
83814-6051
US

V. Phone/Fax

Practice location:
  • Phone: 208-625-4333
  • Fax: 208-625-4334
Mailing address:
  • Phone: 208-625-4333
  • Fax: 208-625-4334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberM15032
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: