Provider Demographics
NPI:1871501460
Name:KANDIEL, KRISTIN (PA)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:KANDIEL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 EVERETT RD
Mailing Address - Street 2:
Mailing Address - City:COLONIE
Mailing Address - State:NY
Mailing Address - Zip Code:12205-1447
Mailing Address - Country:US
Mailing Address - Phone:518-453-9088
Mailing Address - Fax:518-689-6106
Practice Address - Street 1:121 EVERETT RD
Practice Address - Street 2:
Practice Address - City:COLONIE
Practice Address - State:NY
Practice Address - Zip Code:12205-1447
Practice Address - Country:US
Practice Address - Phone:518-453-9088
Practice Address - Fax:518-689-6106
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011341363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02801687Medicaid
NY02801687Medicaid
NY6275L8Medicare PIN