Basic Information
| Provider Information | |||||||||
| NPI: | 1417148743 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATTERN | ||||||||
| FirstName: | KATHERINE | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 650 S COURTENAY PKWY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MERRITT ISLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329524977 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3213942660 | ||||||||
| FaxNumber: | 3213942669 | ||||||||
| Practice Location | |||||||||
| Address1: | 650 S COURTENAY PKWY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MERRITT ISLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329524977 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3213942660 | ||||||||
| FaxNumber: | 3213942669 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2007 | ||||||||
| LastUpdateDate: | 04/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9106262 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | NS448 | 01 | FL | FL MEDICARE | OTHER | 202014 | 01 | NC | MEDCOST | OTHER | 9772073 | 01 | AETNA | OTHER |