Provider Demographics
NPI:1033220934
Name:SHEFNER, KATHLEEN M (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:M
Last Name:SHEFNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KATHLEEN
Other - Middle Name:M
Other - Last Name:HYKIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:475 IRVING AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1756
Mailing Address - Country:US
Mailing Address - Phone:315-471-2646
Mailing Address - Fax:315-471-1762
Practice Address - Street 1:475 IRVING AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1756
Practice Address - Country:US
Practice Address - Phone:315-471-2646
Practice Address - Fax:315-471-1762
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY221218208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
040426016033OtherFIDELIS
NY02212480Medicaid
265416OtherMVP INSURANCE #