Provider Demographics
NPI:1578952974
Name:PURDY, KATIE LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:LYNN
Last Name:PURDY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:LYNN
Other - Last Name:BEDNARIK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:250 3RD ST NW
Mailing Address - Street 2:STE 201
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-4605
Mailing Address - Country:US
Mailing Address - Phone:863-318-9696
Mailing Address - Fax:863-318-8075
Practice Address - Street 1:250 3RD ST NW
Practice Address - Street 2:STE 201
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-4605
Practice Address - Country:US
Practice Address - Phone:863-318-9696
Practice Address - Fax:863-318-8075
Is Sole Proprietor?:No
Enumeration Date:2015-01-22
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108488363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIB452ZMedicare PIN