Basic Information
| Provider Information | |||||||||
| NPI: | 1619956653 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | CATHERINE | ||||||||
| MiddleName: | A | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8674 | ||||||||
| Address2: | 1230 E MAIN ST MANKATO CLINIC LTD | ||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560028674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076251811 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1400 E MADISON AVE STE 400A | ||||||||
| Address2: | |||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560016805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076251811 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2006 | ||||||||
| LastUpdateDate: | 07/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 37871 | MN | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 7K350DA | 01 | MN | BCBS | OTHER | 1202256 | 01 | MN | MEDICA | OTHER | NA2951023823 | 01 | MN | PREFERRED ONE | OTHER | 144719000 | 05 | MN | MEDICAID | 370005354 | 01 | RR MEDICARE | OTHER | 0965525 | 01 | IA | MEDICAID | OTHER | 121155 | 01 | MN | UCARE | OTHER | HP25201 | 01 | MN | HEALTH PARTNERS | OTHER | 410849339 56001 C101 | 01 | CHAMPUS | OTHER | 658425 | 01 | MN | AMERICAS PPO | OTHER |