Provider Demographics
NPI:1225385305
Name:DIMARTINO, KATIE ELIZABETH (PA)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:ELIZABETH
Last Name:DIMARTINO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:ELIZABETH
Other - Last Name:KENNY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2655 RIDGEWAY AVE STE 240
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-4296
Mailing Address - Country:US
Mailing Address - Phone:585-723-7060
Mailing Address - Fax:585-723-7325
Practice Address - Street 1:2655 RIDGEWAY AVE STE 240
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-4296
Practice Address - Country:US
Practice Address - Phone:585-723-7060
Practice Address - Fax:585-723-7325
Is Sole Proprietor?:No
Enumeration Date:2012-08-08
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015698363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03524476Medicaid
NY12434137OtherCAQH