Basic Information
| Provider Information | |||||||||
| NPI: | 1689964462 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | KATRINA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4059 | ||||||||
| Address2: | |||||||||
| City: | WAYNE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 074744059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9738268080 | ||||||||
| FaxNumber: | 8889726480 | ||||||||
| Practice Location | |||||||||
| Address1: | 4215 EDGEWATER DR | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328042206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9738268080 | ||||||||
| FaxNumber: | 8889726480 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2011 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA9105946 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | FB469U | 01 | DC | QSS SCS PTAN | OTHER |