Provider Demographics
NPI:1487365490
Name:LANDRUM, KAITLIN (PA-C)
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:
Last Name:LANDRUM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KAITLIN
Other - Middle Name:
Other - Last Name:MASTERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:6112 E BROWN RD
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205-4955
Mailing Address - Country:US
Mailing Address - Phone:480-924-4422
Mailing Address - Fax:
Practice Address - Street 1:6112 E BROWN RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-4955
Practice Address - Country:US
Practice Address - Phone:480-924-4422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-09
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ9958363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program