Provider Demographics
NPI:1760488001
Name:STAPHOS, KATIE (RPA-C)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:STAPHOS
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 OLD NORTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:ROSLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11576-2252
Mailing Address - Country:US
Mailing Address - Phone:516-484-6777
Mailing Address - Fax:516-484-0037
Practice Address - Street 1:1405 OLD NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:ROSLYN
Practice Address - State:NY
Practice Address - Zip Code:11576-2252
Practice Address - Country:US
Practice Address - Phone:516-484-6777
Practice Address - Fax:516-484-0037
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006980-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant