Provider Demographics
NPI:1356860308
Name:PROBASCO, KAITLYN PAIGE (PA-C)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:PAIGE
Last Name:PROBASCO
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 1:53 IVINS DR
Mailing Address - Street 2:
Mailing Address - City:NEW EGYPT
Mailing Address - State:NJ
Mailing Address - Zip Code:08533-2810
Mailing Address - Country:US
Mailing Address - Phone:732-644-7256
Mailing Address - Fax:
Practice Address - Street 1:7600 RIVER RD
Practice Address - Street 2:
Practice Address - City:NORTH BERGEN
Practice Address - State:NJ
Practice Address - Zip Code:07047-6217
Practice Address - Country:US
Practice Address - Phone:732-644-7256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-11
Last Update Date:2018-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00453600363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant