Provider Demographics
NPI:1073697694
Name:MATTHIS, KATHARINE M (RPA-C)
Entity Type:Individual
Prefix:
First Name:KATHARINE
Middle Name:M
Last Name:MATTHIS
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 KING ST
Mailing Address - Street 2:
Mailing Address - City:OGDENSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13669-1142
Mailing Address - Country:US
Mailing Address - Phone:315-393-3600
Mailing Address - Fax:
Practice Address - Street 1:39 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617-1358
Practice Address - Country:US
Practice Address - Phone:315-379-4700
Practice Address - Fax:315-713-6512
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006534207Q00000X, 363AM0700X
NY006534-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01895252Medicaid