Provider Demographics
NPI:1619526076
Name:HUBER, KATHRYN CHARLOTTE (PA-C)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:CHARLOTTE
Last Name:HUBER
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 1:5130 WOODLAND CT
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-1253
Mailing Address - Country:US
Mailing Address - Phone:651-341-0656
Mailing Address - Fax:
Practice Address - Street 1:5515 UTICA RIDGE RD STE 600
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-3927
Practice Address - Country:US
Practice Address - Phone:563-344-1050
Practice Address - Fax:563-424-4579
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-09
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA107195363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty