Provider Demographics
NPI:1659489920
Name:PEDICORD, KATIE COLLEEN (PA)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:COLLEEN
Last Name:PEDICORD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:COLLEEN
Other - Last Name:ROSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:8230 WALNUT HILL LN
Mailing Address - Street 2:SUITE 808
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4482
Mailing Address - Country:US
Mailing Address - Phone:214-696-8828
Mailing Address - Fax:214-696-1444
Practice Address - Street 1:8230 WALNUT HILL LN
Practice Address - Street 2:SUITE 808
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4482
Practice Address - Country:US
Practice Address - Phone:214-696-8828
Practice Address - Fax:214-696-1444
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04430363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8G0633Medicare ID - Type Unspecified
TX8G0633Medicare UPIN