Provider Demographics
NPI:1497328165
Name:SURBER, KAITLIN ROSE (PA-C)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:ROSE
Last Name:SURBER
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 1:90 ADAMS PL
Mailing Address - Street 2:
Mailing Address - City:DELMAR
Mailing Address - State:NY
Mailing Address - Zip Code:12054-3224
Mailing Address - Country:US
Mailing Address - Phone:518-689-2244
Mailing Address - Fax:518-689-2081
Practice Address - Street 1:90 ADAMS PL
Practice Address - Street 2:
Practice Address - City:DELMAR
Practice Address - State:NY
Practice Address - Zip Code:12054-3224
Practice Address - Country:US
Practice Address - Phone:518-689-2244
Practice Address - Fax:518-689-2081
Is Sole Proprietor?:No
Enumeration Date:2021-07-21
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026830363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant