Provider Demographics
NPI:1922373760
Name:SIMPSON, KATIE MARIE (PA)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:MARIE
Last Name:SIMPSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:MARIE
Other - Last Name:FREDETTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:161 GENESEE ST STE 106
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021-3390
Mailing Address - Country:US
Mailing Address - Phone:315-567-0555
Mailing Address - Fax:315-253-0841
Practice Address - Street 1:161 GENESEE ST STE 106
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021-3390
Practice Address - Country:US
Practice Address - Phone:315-567-0555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-13
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015487363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03443652Medicaid
NY03443652Medicaid