Provider Demographics
NPI:1780970889
Name:FLYNN, KATIE SHOE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:SHOE
Last Name:FLYNN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:KATIE
Other - Middle Name:SUZANNE
Other - Last Name:SHOE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3382 PARIS BLVD
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081-4260
Mailing Address - Country:US
Mailing Address - Phone:614-882-2521
Mailing Address - Fax:614-882-0511
Practice Address - Street 1:3382 PARIS BLVD
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-4260
Practice Address - Country:US
Practice Address - Phone:614-882-2521
Practice Address - Fax:614-882-0511
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-27
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.003252RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0089554Medicaid
OH0089554Medicaid