Provider Demographics
NPI:1184649931
Name:MATTLE, KATHRYN (RPA)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:MATTLE
Suffix:
Gender:F
Credentials:RPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 ISLAND COTTAGE RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14612-2308
Mailing Address - Country:US
Mailing Address - Phone:585-368-6040
Mailing Address - Fax:
Practice Address - Street 1:500 ISLAND COTTAGE RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14612-2308
Practice Address - Country:US
Practice Address - Phone:585-368-6040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009133363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02445187Medicaid
DD4594Medicare ID - Type Unspecified
PA0856Medicare ID - Type Unspecified
NY02445187Medicaid
NY000922004001OtherHEALTHNOW