Provider Demographics
NPI:1154312593
Name:HERREN, KATHY LYNN (PA)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:LYNN
Last Name:HERREN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KATHY
Other - Middle Name:LYNN
Other - Last Name:MAZUR - HERREN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 14890
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12212-4890
Mailing Address - Country:US
Mailing Address - Phone:518-525-5634
Mailing Address - Fax:518-649-4094
Practice Address - Street 1:377 CHURCH ST
Practice Address - Street 2:
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:12866
Practice Address - Country:US
Practice Address - Phone:518-584-4456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004509363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02352454Medicaid
NYCC4203Medicare PIN
NY02352454Medicaid