Healthcare Provider Details

I. General information

NPI: 1194880591
Provider Name (Legal Business Name): KATHERINE J HUNTINGTON PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3017 BLOOMINGTON AVE
MINNEAPOLIS MN
55407-1715
US

IV. Provider business mailing address

3017 BLOOMINGTON AVE
MINNEAPOLIS MN
55407-1715
US

V. Phone/Fax

Practice location:
  • Phone: 612-721-6511
  • Fax: 612-721-0239
Mailing address:
  • Phone: 612-721-6511
  • Fax: 612-721-0239

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number8945
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: