Provider Demographics
NPI:1154389153
Name:WILLENBORG, CATHERINE (PAC)
Entity type:Individual
Prefix:MS
First Name:CATHERINE
Middle Name:
Last Name:WILLENBORG
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MS
Other - First Name:KATE
Other - Middle Name:
Other - Last Name:WILLENBORG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PAC
Mailing Address - Street 1:2898 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94115-1061
Mailing Address - Country:US
Mailing Address - Phone:775-771-1824
Mailing Address - Fax:
Practice Address - Street 1:2898 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-1061
Practice Address - Country:US
Practice Address - Phone:775-771-1824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA972363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100508855Medicaid
NVV102135Medicare PIN
Q65849Medicare UPIN