1174876387 NPI number — KATIE M SMITH PA-C

Table of content: KATIE M SMITH PA-C (NPI 1174876387)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174876387 NPI number — KATIE M SMITH PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
KATIE
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174876387
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/23/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30 MEDICAL PARK
Provider Second Line Business Mailing Address:
SUITE 211
Provider Business Mailing Address City Name:
WHEELING
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26003-6391
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-233-6301
Provider Business Mailing Address Fax Number:
304-233-8803

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30 MEDICAL PARK
Provider Second Line Business Practice Location Address:
SUITE 211
Provider Business Practice Location Address City Name:
WHEELING
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26003-6391
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-233-6301
Provider Business Practice Location Address Fax Number:
304-233-8803
Provider Enumeration Date:
10/25/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  124 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: 01712 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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