Provider Demographics
NPI:1730734831
Name:TOURVILLE, KATELYN (PA-C)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:TOURVILLE
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 1:380 MEESKE AVE
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-3219
Mailing Address - Country:US
Mailing Address - Phone:906-869-2857
Mailing Address - Fax:
Practice Address - Street 1:1401 PRESQUE ISLE AVE-HEALTH CENTER
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855
Practice Address - Country:US
Practice Address - Phone:906-227-2355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-06
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601009457363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601009457OtherMICHIGAN PHYSICIAN ASSISTANT LICENSE