Provider Demographics
NPI:1285943654
Name:GAINES, KATRINA ARMIDA CARDENAS (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KATRINA
Middle Name:ARMIDA CARDENAS
Last Name:GAINES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATRINA
Other - Middle Name:ARMIDA
Other - Last Name:CARDENAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2108 E THOMAS RD STE 130
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-0008
Mailing Address - Country:US
Mailing Address - Phone:602-933-3124
Mailing Address - Fax:480-256-3682
Practice Address - Street 1:6524 W SACK DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-7178
Practice Address - Country:US
Practice Address - Phone:602-933-0016
Practice Address - Fax:602-933-4318
Is Sole Proprietor?:No
Enumeration Date:2010-10-01
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4738363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ564234Medicaid