Provider Demographics
NPI:1386606093
Name:MOUDY, KATHLEEN ELIZABETH (PA)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ELIZABETH
Last Name:MOUDY
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:PO BOX 421
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0421
Mailing Address - Country:US
Mailing Address - Phone:509-252-1900
Mailing Address - Fax:
Practice Address - Street 1:9911 N NEVADA ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99218-1298
Practice Address - Country:US
Practice Address - Phone:509-626-9430
Practice Address - Fax:509-227-7070
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003530363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8345936Medicaid