Provider Demographics
NPI:1437534294
Name:GODSHALK, KATHRYN MAUREEN (PA)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:MAUREEN
Last Name:GODSHALK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1561 LONG POND RD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-4117
Mailing Address - Country:US
Mailing Address - Phone:585-368-6500
Mailing Address - Fax:585-368-6501
Practice Address - Street 1:1561 LONG POND RD
Practice Address - Street 2:SUITE 303
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-4117
Practice Address - Country:US
Practice Address - Phone:585-368-6500
Practice Address - Fax:585-368-6501
Is Sole Proprietor?:No
Enumeration Date:2015-07-22
Last Update Date:2015-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018817363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04247536Medicaid
NYJ400249151-GRPBA0017Medicare PIN
NY04247536Medicaid