Healthcare Provider Details

I. General information

NPI: 1629623814
Provider Name (Legal Business Name): KAITLYN R SMITH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2019
Last Update Date: 07/14/2021
Certification Date: 07/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 UNIVERSITY DR
WEST LIBERTY WV
26074-1082
US

IV. Provider business mailing address

501 MORRIS STREET PO BOX 1547
CHARLESTON WV
25326-1547
US

V. Phone/Fax

Practice location:
  • Phone: 304-336-5000
  • Fax:
Mailing address:
  • Phone: 304-388-6004
  • Fax: 304-388-3360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2431
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: