Provider Demographics
NPI:1750734604
Name:HERDEN, KATHRYN DIANNE (PA-C)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:DIANNE
Last Name:HERDEN
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 1:7560 RED BUG LAKE RD STE 2048
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-6591
Mailing Address - Country:US
Mailing Address - Phone:407-366-8856
Mailing Address - Fax:407-977-4319
Practice Address - Street 1:7560 RED BUG LAKE RD STE 2048
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-6591
Practice Address - Country:US
Practice Address - Phone:407-366-8856
Practice Address - Fax:407-977-4319
Is Sole Proprietor?:No
Enumeration Date:2016-07-15
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9110990363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant