Healthcare Provider Details

I. General information

NPI: 1992008759
Provider Name (Legal Business Name): KATHRYN CPAK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2010
Last Update Date: 03/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 RIVER CENTRE DR
PORT HURON MI
48060-4463
US

IV. Provider business mailing address

940 RIVER CENTRE DR
PORT HURON MI
48060-4463
US

V. Phone/Fax

Practice location:
  • Phone: 810-985-4900
  • Fax:
Mailing address:
  • Phone: 810-985-4900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5601005859
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: