Healthcare Provider Details

I. General information

NPI: 1689913410
Provider Name (Legal Business Name): HEATHER M KATHAWA PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2013
Last Update Date: 05/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18101 OAKWOOD BLVD EMERGENCY DEPT
DEARBORN MI
48124-4089
US

IV. Provider business mailing address

265 BROOKVIEW CENTRE WAY SUITE 400
KNOXVILLE TN
37919-4049
US

V. Phone/Fax

Practice location:
  • Phone: 313-593-8780
  • Fax: 313-436-2864
Mailing address:
  • Phone: 800-342-2898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601006579
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: