Healthcare Provider Details

I. General information

NPI: 1740230077
Provider Name (Legal Business Name): KATHERINE GALE ERVIE PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 03/24/2025
Certification Date: 03/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1706 PROSPECT DR
MACON MO
63552-2615
US

IV. Provider business mailing address

1706 PROSPECT DR
MACON MO
63552-2615
US

V. Phone/Fax

Practice location:
  • Phone: 660-385-1006
  • Fax: 660-890-8422
Mailing address:
  • Phone: 660-385-1006
  • Fax: 660-890-8422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number114815
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: