Provider Demographics
NPI:1952017519
Name:BACON, KATIE LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:LYNN
Last Name:BACON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1009 S KENT ST
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-4571
Mailing Address - Country:US
Mailing Address - Phone:540-497-1612
Mailing Address - Fax:
Practice Address - Street 1:3745 HOLLAND RD STE 200
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-2866
Practice Address - Country:US
Practice Address - Phone:757-395-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-26
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1180756363A00000X
VA0110009105363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant