Provider Demographics
NPI:1811588494
Name:SMITH, KATLYN ANN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KATLYN
Middle Name:ANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:KATLYN
Other - Middle Name:ANN
Other - Last Name:BOBOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4 MEMORIAL DR STE 130
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6704
Mailing Address - Country:US
Mailing Address - Phone:618-463-7600
Mailing Address - Fax:
Practice Address - Street 1:4 MEMORIAL DR STE 130
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-6704
Practice Address - Country:US
Practice Address - Phone:618-463-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-27
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA363A00000X
MO085009225363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1181613OtherNCCPA