Provider Demographics
NPI:1144517947
Name:PACK, KATRINA MARIE (MD)
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:MARIE
Last Name:PACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATRINA
Other - Middle Name:MARIE
Other - Last Name:PACK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:4021 AVENUE B
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-4602
Mailing Address - Country:US
Mailing Address - Phone:308-635-7511
Mailing Address - Fax:
Practice Address - Street 1:300 EXEMPLA CIR
Practice Address - Street 2:SUITE 230
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-3397
Practice Address - Country:US
Practice Address - Phone:303-689-6591
Practice Address - Fax:303-306-7753
Is Sole Proprietor?:No
Enumeration Date:2011-06-30
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT2003632084N0400X
CODR.00568962084N0400X, 2084N0008X
KS04-456672084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0008XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeuromuscular Medicine
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CODR.0056896OtherCOLORADO MEDICAL LICENSE