Provider Demographics
NPI:1588746366
Name:REZAC, KATHRYN MICHELLE PUTNAM (PA)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:MICHELLE PUTNAM
Last Name:REZAC
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:MICHELLE
Other - Last Name:PUTNAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:18167 US HIGHWAY 19 N
Mailing Address - Street 2:SUITE 650
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33764-3528
Mailing Address - Country:US
Mailing Address - Phone:800-507-8874
Mailing Address - Fax:
Practice Address - Street 1:2100 SE BLUE PKWY
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64063-1007
Practice Address - Country:US
Practice Address - Phone:816-282-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005001379363AM0700X
KS1500996363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP87525Medicare UPIN