Provider Demographics
NPI:1396210050
Name:SPADALIK, KATELYN MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:MARIE
Last Name:SPADALIK
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 1:260 E MIDDLE COUNTRY RD STE 208
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2925
Mailing Address - Country:US
Mailing Address - Phone:631-863-3223
Mailing Address - Fax:631-863-3334
Practice Address - Street 1:2701 QUEENS PLZ N FL 10
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-4022
Practice Address - Country:US
Practice Address - Phone:516-233-9256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-09
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022466363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant