Provider Demographics
NPI:1669484440
Name:KNISELY, KATHRYN M (PA)
Entity Type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:M
Last Name:KNISELY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:M
Other - Last Name:PREM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:192 PARK CLUB LANE SUITE 100
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221
Mailing Address - Country:US
Mailing Address - Phone:716-204-1101
Mailing Address - Fax:716-204-0914
Practice Address - Street 1:192 PARK CLUB LANE SUITE 100
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221
Practice Address - Country:US
Practice Address - Phone:716-204-1101
Practice Address - Fax:716-204-0914
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010007363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ31329Medicare UPIN
NYBA0215Medicare ID - Type Unspecified