Provider Demographics
NPI:1487214953
Name:MCKENNA-MANTICA, CAITLIN C (PA-C)
Entity Type:Individual
Prefix:
First Name:CAITLIN
Middle Name:C
Last Name:MCKENNA-MANTICA
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 1:43 NEW SCOTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-3478
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:43 NEW SCOTLAND AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3412
Practice Address - Country:US
Practice Address - Phone:518-262-3125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-17
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant