Provider Demographics
NPI:1013988989
Name:FARRIS, KATHERINE (MD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:FARRIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 S BOYLAN AVE
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27603-1802
Mailing Address - Country:US
Mailing Address - Phone:919-833-7534
Mailing Address - Fax:
Practice Address - Street 1:3000 MAPLEWOOD AVE
Practice Address - Street 2:SUITE 112
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4002
Practice Address - Country:US
Practice Address - Phone:336-768-2980
Practice Address - Fax:336-765-6599
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA217062207Q00000X
NC2009-00506207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2017661Medicaid
H91933Medicare UPIN
MA2017661Medicaid