Provider Demographics
NPI:1366497547
Name:HALL, KATHERINE BROOKE (PA)
Entity type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:BROOKE
Last Name:HALL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:KATHERINE
Other - Middle Name:BROOKE
Other - Last Name:HARPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:70 MEDICAL CENTER CIR
Mailing Address - Street 2:SUITE 301
Mailing Address - City:FISHERSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22939-2273
Mailing Address - Country:US
Mailing Address - Phone:540-448-8819
Mailing Address - Fax:
Practice Address - Street 1:1125 E POLSTON AVE STE B
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-6045
Practice Address - Country:US
Practice Address - Phone:208-758-0075
Practice Address - Fax:208-758-0076
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10005306363A00000X
VA0110002075363AM0700X
IDPA1846363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010235421Medicaid
VA008469E50Medicare ID - Type Unspecified
VA010235421Medicaid