Provider Demographics
NPI:1689964462
Name:SMITH, KATRINA J (PA)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:J
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 4059
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07474-4059
Mailing Address - Country:US
Mailing Address - Phone:973-826-8080
Mailing Address - Fax:888-972-6480
Practice Address - Street 1:4215 EDGEWATER DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-2206
Practice Address - Country:US
Practice Address - Phone:973-826-8080
Practice Address - Fax:888-972-6480
Is Sole Proprietor?:No
Enumeration Date:2011-04-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9105946363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCFB469UOtherQSS SCS PTAN
FLFB469ZMedicare PIN