Provider Demographics
NPI:1255616124
Name:SCHUPP, KAITLIN M (PA)
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:M
Last Name:SCHUPP
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 N HAMILTON RD
Mailing Address - Street 2:
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230-8708
Mailing Address - Country:US
Mailing Address - Phone:614-473-9519
Mailing Address - Fax:614-473-9543
Practice Address - Street 1:925 N HAMILTON RD
Practice Address - Street 2:
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230-8708
Practice Address - Country:US
Practice Address - Phone:614-473-9519
Practice Address - Fax:614-473-9543
Is Sole Proprietor?:No
Enumeration Date:2011-10-11
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.003369363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical