Provider Demographics
NPI:1346788916
Name:SMITH, KATHERINE M (PAC)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:M
Other - Last Name:KAVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:2725 S 144TH ST STE 212
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-5253
Mailing Address - Country:US
Mailing Address - Phone:402-637-0800
Mailing Address - Fax:402-637-0808
Practice Address - Street 1:2725 S 144TH ST STE 212
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-5253
Practice Address - Country:US
Practice Address - Phone:402-637-0800
Practice Address - Fax:402-637-0808
Is Sole Proprietor?:No
Enumeration Date:2017-02-03
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2104363A00000X
IA086230363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant