Provider Demographics
NPI:1629601224
Name:JAGMIN, KATIE MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:MARIE
Last Name:JAGMIN
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 1:95 DUNN DR STE 123
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22556-1503
Mailing Address - Country:US
Mailing Address - Phone:703-523-9570
Mailing Address - Fax:
Practice Address - Street 1:95 DUNN DR STE 123
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22556-1503
Practice Address - Country:US
Practice Address - Phone:703-523-9570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-21
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027201363A00000X
MDC0008632363A00000X
VA0110-008804363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant