Basic Information
Provider Information | |||||||||
NPI: | 1396997227 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SILVA | ||||||||
FirstName: | KATE | ||||||||
MiddleName: | ELISABETH | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.A.-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1005 MAR WALT DRIVE | ||||||||
Address2: | FAMILY MEDICINE DEPT | ||||||||
City: | FORT WALTON BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 325476796 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8508636600 | ||||||||
FaxNumber: | 8508620977 | ||||||||
Practice Location | |||||||||
Address1: | 1005 MAR WALT DRIVE | ||||||||
Address2: | IMMEDIATE CARE DEPARTMENT | ||||||||
City: | FORT WALTON BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 325476796 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8508638219 | ||||||||
FaxNumber: | 8508638249 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/22/2008 | ||||||||
LastUpdateDate: | 02/02/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/15/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9103184 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | Y04CS | 01 |   | BCBSFL | OTHER | 003928800 | 05 | FL |   | MEDICAID |