Basic Information
| Provider Information | |||||||||
| NPI: | 1902189632 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAURER | ||||||||
| FirstName: | KATELYN | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WITTE | ||||||||
| OtherFirstName: | KATELYN | ||||||||
| OtherMiddleName: | E | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4207 LAKE BOONE TRL | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276076684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197841410 | ||||||||
| FaxNumber: | 9197841409 | ||||||||
| Practice Location | |||||||||
| Address1: | 4207 LAKE BOONE TRL | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276076684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197841410 | ||||||||
| FaxNumber: | 9197841409 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2011 | ||||||||
| LastUpdateDate: | 11/18/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 50-003301 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 0010-04375 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.