MEDICARE: KATHLEEN MANTZ GOTWALS PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	MA002439L	PA

General Provider Information

NPI Number	:	1033119482
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN MANTZ GOTWALS PA-C

Provider Business Mailing Address
First Line	:	PO BOX 216
Second Line	:
City	:	PENNSBURG
State	:	PA
Zip	:	18073-0216
Country	:	US
Telephone Number	:	215-679-8071
Fax Number	:	215-541-4171

Provider Business Practice Location Address
First Line	:	2781 GERYVILLE PIKE
Second Line	:
City	:	PENNSBURG
State	:	PA
Zip	:	18073-2306
Country	:	US
Telephone Number	:	215-679-8071
Fax Number	:	215-541-4171

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/28/2005
Last Update Date	:	07/08/2007

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