Provider Demographics
NPI:1306153432
Name:TETRAULT, KATHERINE A (PA)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:A
Last Name:TETRAULT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:244 TUKE LN
Mailing Address - Street 2:
Mailing Address - City:TWIN BRIDGES
Mailing Address - State:MT
Mailing Address - Zip Code:59754-9735
Mailing Address - Country:US
Mailing Address - Phone:406-925-9707
Mailing Address - Fax:
Practice Address - Street 1:600 MT HIGHWAY 91 S
Practice Address - Street 2:
Practice Address - City:DILLON
Practice Address - State:MT
Practice Address - Zip Code:59725-7379
Practice Address - Country:US
Practice Address - Phone:406-683-3051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-10
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003834363A00000X
MTMED-PAC-LIC-18647363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTMED-PAC-LIC-18647OtherSTATE OF MONTANA PHYSICIAN ASSISTANT LICENSE