Basic Information
| Provider Information | |||||||||
| NPI: | 1689908550 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KATONA | ||||||||
| FirstName: | KERRI | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PREDIGER | ||||||||
| OtherFirstName: | KERRI | ||||||||
| OtherMiddleName: | ANNE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 850 N OTSEGO AVE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | GAYLORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497351568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897317708 | ||||||||
| FaxNumber: | 9897317929 | ||||||||
| Practice Location | |||||||||
| Address1: | 3696 S STRAITS HWY | ||||||||
| Address2: | |||||||||
| City: | INDIAN RIVER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497495136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2312380581 | ||||||||
| FaxNumber: | 2312380586 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2009 | ||||||||
| LastUpdateDate: | 01/30/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5601005615 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | OF96004 | 01 | MI | MEDICARE GROUP PTAN | OTHER |