Provider Demographics
NPI:1780123968
Name:LISABETH, KATIE ANN (PA-C)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:ANN
Last Name:LISABETH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:ANN
Other - Last Name:POLASKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:5140 LIBERTY AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15224-2215
Mailing Address - Country:US
Mailing Address - Phone:412-681-2300
Mailing Address - Fax:
Practice Address - Street 1:5140 LIBERTY AVE STE 102
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15224-2215
Practice Address - Country:US
Practice Address - Phone:412-681-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-21
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA061808363AM0700X
MI5601008045363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
13974792OtherCAQH