Provider Demographics
NPI:1487072120
Name:STORRS, KATIE (PA-C)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:STORRS
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:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6400
Mailing Address - Fax:
Practice Address - Street 1:520 DOUGLAS BLVD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-8307
Practice Address - Country:US
Practice Address - Phone:903-593-1721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-31
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA08914363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8893NPOtherBCBS
TX772195OtherMEDICARE
TX345826701Medicaid
TXP02207519OtherMEDICARE RAIL ROAD
TX75-2616977-007OtherTRICARE
TX345826702Medicaid
TXP01479347OtherRAIL ROAD