Basic Information
| Provider Information | |||||||||
| NPI: | 1295028744 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ETTEFAGH | ||||||||
| FirstName: | KATE | ||||||||
| MiddleName: | SCOTT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 E WENDOVER AVE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274011230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368323150 | ||||||||
| FaxNumber: | 3368323151 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 E WENDOVER AVE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274011230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368323150 | ||||||||
| FaxNumber: | 3368323151 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2011 | ||||||||
| LastUpdateDate: | 08/18/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 2014-01508 | NC | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.