=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982340048
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATELYN SCOTT O'CONNOR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2022
-----------------------------------------------------
Last Update Date | 06/15/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2729 LOFTYVIEW DR
-----------------------------------------------------
City | TORRANCE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90505-7225
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 785-766-5063
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2729 LOFTYVIEW DR
-----------------------------------------------------
City | TORRANCE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90505-7225
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 785-766-5063
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA61203
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------