Provider Demographics
NPI:1124037585
Name:BETZ, KATHRYN ODOM (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:ODOM
Last Name:BETZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:KATHRYN
Other - Middle Name:ELIZABETH
Other - Last Name:ODOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 945395
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30394-5395
Mailing Address - Country:US
Mailing Address - Phone:888-280-9533
Mailing Address - Fax:919-873-9821
Practice Address - Street 1:3050 DURALEIGH RD
Practice Address - Street 2:SUITE 201
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-5448
Practice Address - Country:US
Practice Address - Phone:984-215-6950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-00279363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC185108OtherMEDCOST
NC2628885OtherUHC
NCP00295148Medicare PIN
NC2765152Medicare PIN
NC185108OtherMEDCOST