Healthcare Provider Details

I. General information

NPI: 1386035509
Provider Name (Legal Business Name): KATIE MEZYNSKI WHITWORTH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATIE TYSON MEZYNSKI PA-C

II. Dates (important events)

Enumeration Date: 02/10/2015
Last Update Date: 02/18/2023
Certification Date: 02/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 NEW BERN AVE
RALEIGH NC
27610-1231
US

IV. Provider business mailing address

3809 COMPUTER DR STE 100
RALEIGH NC
27609-6518
US

V. Phone/Fax

Practice location:
  • Phone: 919-350-8779
  • Fax:
Mailing address:
  • Phone: 919-781-9078
  • Fax: 919-719-0147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-05539
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: