Provider Demographics
NPI:1396095360
Name:SONG, KATHY (PA-C)
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:SONG
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 1:2868 ACTON RD
Mailing Address - Street 2:
Mailing Address - City:VESTAVIA
Mailing Address - State:AL
Mailing Address - Zip Code:35243-2502
Mailing Address - Country:US
Mailing Address - Phone:205-379-6075
Mailing Address - Fax:866-702-0880
Practice Address - Street 1:356110 E 930 RD
Practice Address - Street 2:
Practice Address - City:STROUD
Practice Address - State:OK
Practice Address - Zip Code:74079-5184
Practice Address - Country:US
Practice Address - Phone:918-968-9531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-17
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1287363AM0700X
OK2160363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical