Healthcare Provider Details

I. General information

NPI: 1780970889
Provider Name (Legal Business Name): KATIE SHOE FLYNN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MISS KATIE SUZANNE SHOE

II. Dates (important events)

Enumeration Date: 06/27/2011
Last Update Date: 08/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3382 PARIS BLVD
WESTERVILLE OH
43081-4260
US

IV. Provider business mailing address

3382 PARIS BLVD
WESTERVILLE OH
43081-4260
US

V. Phone/Fax

Practice location:
  • Phone: 614-882-2521
  • Fax: 614-882-0511
Mailing address:
  • Phone: 614-882-2521
  • Fax: 614-882-0511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.003252RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: