Provider Demographics
NPI:1194730762
Name:KNIGHT, KERRY M (PAC)
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:M
Last Name:KNIGHT
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:KERRY
Other - Middle Name:M
Other - Last Name:KORTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:5115 N DYSART RD
Mailing Address - Street 2:SUITE 202 #147
Mailing Address - City:LITCHFIELD PARK
Mailing Address - State:AZ
Mailing Address - Zip Code:85340-3032
Mailing Address - Country:US
Mailing Address - Phone:623-474-2450
Mailing Address - Fax:623-474-2450
Practice Address - Street 1:4741 N. ALDEA RD. WEST
Practice Address - Street 2:
Practice Address - City:LITCHFIELD PARK
Practice Address - State:AZ
Practice Address - Zip Code:85340
Practice Address - Country:US
Practice Address - Phone:623-474-2450
Practice Address - Fax:623-474-2450
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3281363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ988462Medicaid
AZ988462Medicaid