Provider Demographics
NPI:1699774174
Name:MATTINGLY, KATHERINE ANN (PA-C)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ANN
Last Name:MATTINGLY
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 1:122 WYOMING ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45409-2731
Mailing Address - Country:US
Mailing Address - Phone:937-223-4461
Mailing Address - Fax:937-224-1945
Practice Address - Street 1:122 WYOMING ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2731
Practice Address - Country:US
Practice Address - Phone:937-223-4461
Practice Address - Fax:937-224-1945
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50002181363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0067797Medicaid
OHMAPA23725Medicare PIN
OH0067797Medicaid