Provider Demographics
NPI:1508417809
Name:SHOTWELL, KAITLYN JESSICA (PA-C)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:JESSICA
Last Name:SHOTWELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2803 MEDICAL CAMPUS DRIVE
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR JOHNSON AFB
Mailing Address - State:NC
Mailing Address - Zip Code:27531
Mailing Address - Country:US
Mailing Address - Phone:919-722-1802
Mailing Address - Fax:919-722-4665
Practice Address - Street 1:2803 MEDICAL CAMPUS DRIVE
Practice Address - Street 2:
Practice Address - City:SEYMOUR JOHNSON AFB
Practice Address - State:NC
Practice Address - Zip Code:27531
Practice Address - Country:US
Practice Address - Phone:919-722-1802
Practice Address - Fax:919-722-4665
Is Sole Proprietor?:No
Enumeration Date:2019-09-27
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-09512363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0010-09512OtherNC LICENSE