Provider Demographics
NPI:1205562394
Name:HART, KAITLIN M (PA-C)
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:M
Last Name:HART
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:18444 N 25TH AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-1266
Mailing Address - Country:US
Mailing Address - Phone:866-974-2673
Mailing Address - Fax:866-939-2673
Practice Address - Street 1:15525 N 83RD AVE STE 104
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-5820
Practice Address - Country:US
Practice Address - Phone:480-964-2273
Practice Address - Fax:623-505-3772
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-29
Last Update Date:2025-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9257363A00000X, 363LP0808X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program