Provider Demographics
NPI:1790416311
Name:SPOSATO, KALIE MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:KALIE
Middle Name:MARIE
Last Name:SPOSATO
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 1:909 STRAWBERRY LN
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NY
Mailing Address - Zip Code:13624-1409
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:909 STRAWBERRY LN
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NY
Practice Address - Zip Code:13624-1409
Practice Address - Country:US
Practice Address - Phone:315-686-2094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-23
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030765-01363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant