Provider Demographics
NPI:1518435122
Name:SMITH, KATELYN MARIE (PA-S)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:19 BRADHURST AVE STE 3100N
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:NY
Mailing Address - Zip Code:10532-2140
Mailing Address - Country:US
Mailing Address - Phone:914-909-9018
Mailing Address - Fax:914-909-9028
Practice Address - Street 1:100 WOODS RD
Practice Address - Street 2:
Practice Address - City:VALHALLA
Practice Address - State:NY
Practice Address - Zip Code:10595
Practice Address - Country:US
Practice Address - Phone:914-493-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-13
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY024181363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY024181OtherNYS LICENSE