Provider Demographics
NPI:1033684196
Name:LIGHTCAP, KATELIN (PA-C)
Entity Type:Individual
Prefix:
First Name:KATELIN
Middle Name:
Last Name:LIGHTCAP
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1445 AMERICA AVE
Mailing Address - Street 2:
Mailing Address - City:WEST BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704-4034
Mailing Address - Country:US
Mailing Address - Phone:541-378-8725
Mailing Address - Fax:
Practice Address - Street 1:82 MIDDLE COUNTRY RD
Practice Address - Street 2:
Practice Address - City:CORAM
Practice Address - State:NY
Practice Address - Zip Code:11727-4460
Practice Address - Country:US
Practice Address - Phone:631-320-2220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-04
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
NY028808-01363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician