Provider Demographics
NPI:1699000638
Name:WARREN, KATIE (PA-C)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:WARREN
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:PO BOX 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:336-718-4700
Mailing Address - Fax:
Practice Address - Street 1:50 W 4TH ST APT 10
Practice Address - Street 2:SUITE 10
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-4089
Practice Address - Country:US
Practice Address - Phone:336-718-4700
Practice Address - Fax:336-718-4702
Is Sole Proprietor?:No
Enumeration Date:2009-10-08
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC363A00000X
PAMA054158363AM0700X
NC0010-03309363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNC4836AOtherMEDICARE PTAN, INDIVIDUAL
NC232009OtherMEDICARE PTAN, GROUP CMCNE