Provider Demographics
NPI:1275161358
Name:PATE, KATHERINE LYNN (PA-C)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:LYNN
Last Name:PATE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4945 BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32927-9105
Mailing Address - Country:US
Mailing Address - Phone:208-651-4933
Mailing Address - Fax:
Practice Address - Street 1:5005 PORT ST JOHN PKWY STE 2200
Practice Address - Street 2:
Practice Address - City:PORT ST JOHN
Practice Address - State:FL
Practice Address - Zip Code:32927-4305
Practice Address - Country:US
Practice Address - Phone:321-433-2247
Practice Address - Fax:803-936-8097
Is Sole Proprietor?:No
Enumeration Date:2020-04-01
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4461363AS0400X
390200000X
FL9118332363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program