Healthcare Provider Details

I. General information

NPI: 1326099953
Provider Name (Legal Business Name): KATHERINE MEDFORD PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 03/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3155 MAPLEWOOD AVE
WINSTON-SALEM NC
27103
US

IV. Provider business mailing address

3010 TRENWEST DR
WINSTON SALEM NC
27103-3208
US

V. Phone/Fax

Practice location:
  • Phone: 336-794-4372
  • Fax: 336-659-2379
Mailing address:
  • Phone: 336-970-5000
  • Fax: 336-970-5298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number102286
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: