Basic Information
Provider Information | |||||||||
NPI: | 1285943654 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GAINES | ||||||||
FirstName: | KATRINA | ||||||||
MiddleName: | ARMIDA CARDENAS | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CARDENAS | ||||||||
OtherFirstName: | KATRINA | ||||||||
OtherMiddleName: | ARMIDA | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2940 E. BANNER GATEWAY DRIVE | ||||||||
Address2: | SUITE 450 | ||||||||
City: | GILBERT | ||||||||
State: | AZ | ||||||||
PostalCode: | 85234 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4802566444 | ||||||||
FaxNumber: | 4802563682 | ||||||||
Practice Location | |||||||||
Address1: | 2946 E BANNER GATEWAY DRIVE | ||||||||
Address2: |   | ||||||||
City: | GILBERT | ||||||||
State: | AZ | ||||||||
PostalCode: | 85234 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4802566444 | ||||||||
FaxNumber: | 4802563682 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/01/2010 | ||||||||
LastUpdateDate: | 09/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/22/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 4738 | AZ | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | 4738 | AZ | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.