Provider Demographics
NPI: | 1467544320 |
---|---|
Name: | WINANS, KATIE ELLEN (PAC) |
Entity Type: | Individual |
Prefix: | MS |
First Name: | KATIE |
Middle Name: | ELLEN |
Last Name: | WINANS |
Suffix: | |
Gender: | F |
Credentials: | PAC |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 4421 NE ST JOHNS RD |
Mailing Address - Street 2: | SUITE F |
Mailing Address - City: | VANCOUVER |
Mailing Address - State: | WA |
Mailing Address - Zip Code: | 98661-2573 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 360-695-9922 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 4421 NE ST JOHNS RD |
Practice Address - Street 2: | SUITE F |
Practice Address - City: | VANCOUVER |
Practice Address - State: | WA |
Practice Address - Zip Code: | 98661-2573 |
Practice Address - Country: | US |
Practice Address - Phone: | 360-695-9922 |
Practice Address - Fax: | 360-695-1310 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-09-29 |
Last Update Date: | 2023-03-07 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OR | PA01113 | 363A00000X |
WA | PA60217469 | 363A00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
WA | PA60217469 | Other | LICENSE |
1070416 | Other | NCCPA NATIONAL | |
OR | PA01113 | Other | OREGON MED BOARD |
OR | PA01113 | Other | OREGON MED BOARD |