Provider Demographics
NPI:1134314727
Name:MABE, KATHRYN SIMPSON (PA)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:SIMPSON
Last Name:MABE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:KATHRYN
Other - Middle Name:ELIZABETH
Other - Last Name:SIMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:213 S JEFFERSON ST STE 1006
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:540-224-5715
Mailing Address - Fax:540-224-5684
Practice Address - Street 1:3707 BRAMBLETON AVE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-3658
Practice Address - Country:US
Practice Address - Phone:540-725-7800
Practice Address - Fax:540-989-6752
Is Sole Proprietor?:No
Enumeration Date:2007-09-07
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002606363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0110002606OtherLICENSE
VA0110002606OtherLICENSE
VA014934C99Medicare PIN