Provider Demographics
NPI:1356359889
Name:LATTERNER, KIM MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:MARIE
Last Name:LATTERNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:MARIE
Other - Last Name:MYERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:115 HICKORY DR
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:17345-9502
Mailing Address - Country:US
Mailing Address - Phone:717-266-6784
Mailing Address - Fax:
Practice Address - Street 1:115 HICKORY DR
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:PA
Practice Address - Zip Code:17345-9502
Practice Address - Country:US
Practice Address - Phone:717-266-6784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0002815363A00000X
PAMA001899L363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1933965OtherHIGHMARK BLUE SHIELD
PA1565458OtherGATEWAY-WMG
PA103356Medicare PIN
PA1565458OtherGATEWAY-WMG