Provider Demographics
NPI:1679048458
Name:MEHERN, KAITLYN MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:MARIE
Last Name:MEHERN
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 1:13 DEAUVILLE CT
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-2105
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:80 SEYMOUR ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06102-8000
Practice Address - Country:US
Practice Address - Phone:860-545-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-09
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
CT4289363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical