Provider Demographics
NPI:1497195556
Name:KOLB, KATHERINE E (PA)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:E
Last Name:KOLB
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:E
Other - Last Name:KOLB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:492 N SWALLOW LN
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-7919
Mailing Address - Country:US
Mailing Address - Phone:480-467-8975
Mailing Address - Fax:
Practice Address - Street 1:1250 S CLEARVIEW AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-3378
Practice Address - Country:US
Practice Address - Phone:480-467-8975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-02
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA08704363A00000X
363AM0700X
AZ5901363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX336161001Medicaid
TX326813YKN5Medicare PIN