Provider Demographics
NPI:1144984451
Name:LILES, KATELYN MCCLUSKEY (PA-C)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:MCCLUSKEY
Last Name:LILES
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 1:2778 HIGHWAY 51 S
Mailing Address - Street 2:
Mailing Address - City:SENATOBIA
Mailing Address - State:MS
Mailing Address - Zip Code:38668-9403
Mailing Address - Country:US
Mailing Address - Phone:662-560-5966
Mailing Address - Fax:
Practice Address - Street 1:2778 HIGHWAY 51 S
Practice Address - Street 2:
Practice Address - City:SENATOBIA
Practice Address - State:MS
Practice Address - Zip Code:38668-9403
Practice Address - Country:US
Practice Address - Phone:662-560-5966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-25
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA00605363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSPA00605OtherPHYSICIAN ASSISTANT