Provider Demographics
NPI:1174876387
Name:SMITH, KATIE M (PA-C)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:M
Last Name:SMITH
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 1:30 MEDICAL PARK
Mailing Address - Street 2:SUITE 211
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-6391
Mailing Address - Country:US
Mailing Address - Phone:304-233-6301
Mailing Address - Fax:304-233-8803
Practice Address - Street 1:30 MEDICAL PARK
Practice Address - Street 2:SUITE 211
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-6391
Practice Address - Country:US
Practice Address - Phone:304-233-6301
Practice Address - Fax:304-233-8803
Is Sole Proprietor?:No
Enumeration Date:2012-10-25
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV124363AM0700X
WV01712363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical