Provider Demographics
NPI:1053984336
Name:ANDERSON, KATELYN MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:MARIE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATELYN
Other - Middle Name:MARIE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:561 POLECAT ROAD
Mailing Address - Street 2:
Mailing Address - City:LANDISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17040
Mailing Address - Country:US
Mailing Address - Phone:717-636-2586
Mailing Address - Fax:
Practice Address - Street 1:111 S FRONT ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17101-2010
Practice Address - Country:US
Practice Address - Phone:717-636-2586
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-23
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA062741363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant