Provider Demographics
NPI:1912561226
Name:SHIELDS, KATIE ROGERS (PA-C)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:ROGERS
Last Name:SHIELDS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:SUZANNE
Other - Last Name:ROGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 13262
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30324-0262
Mailing Address - Country:US
Mailing Address - Phone:479-462-8492
Mailing Address - Fax:
Practice Address - Street 1:5785 ROSWELL RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-4903
Practice Address - Country:US
Practice Address - Phone:140-490-7482
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-23
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1650363A00000X
GA9898363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant