Provider Demographics
NPI:1861796534
Name:KEPHART, KATHLEEN MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
Last Name:KEPHART
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 1:512 E PARK AVE
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16601-3747
Mailing Address - Country:US
Mailing Address - Phone:814-935-9152
Mailing Address - Fax:
Practice Address - Street 1:202 COVE FORGE RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:PA
Practice Address - Zip Code:16693-7138
Practice Address - Country:US
Practice Address - Phone:814-832-2131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-10
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA053950363A00000X, 363AM0700X
PAOA002469363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant