Provider Demographics
NPI:1790015691
Name:WASHAM, KATHERINE ALISON (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ALISON
Last Name:WASHAM
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 1:12221 MERIT DR STE 1610
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75251-2204
Mailing Address - Country:US
Mailing Address - Phone:214-217-1911
Mailing Address - Fax:214-217-1912
Practice Address - Street 1:12221 MERIT DR STE 1610
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75251-2204
Practice Address - Country:US
Practice Address - Phone:214-217-1911
Practice Address - Fax:214-217-1912
Is Sole Proprietor?:No
Enumeration Date:2009-12-28
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06627363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX281313103Medicaid
TX281313101Medicaid
TX281313102Medicaid
TX281313101Medicaid
TXTXB123700Medicare PIN
TXTXB138261Medicare PIN
TX281313103Medicaid