Provider Demographics
NPI:1902209729
Name:CROTTY, KATHLEEN BUBNACK (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:BUBNACK
Last Name:CROTTY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:BUBNACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 PARK STREET
Mailing Address - Street 2:GLENS FALLS HOSPITAL - CREDENTIALING
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801
Mailing Address - Country:US
Mailing Address - Phone:518-926-5924
Mailing Address - Fax:518-926-6983
Practice Address - Street 1:102 PARK STREET
Practice Address - Street 2:GLENS FALLS HOSPITAL NEUROLOGY
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801
Practice Address - Country:US
Practice Address - Phone:518-926-2940
Practice Address - Fax:518-926-2941
Is Sole Proprietor?:No
Enumeration Date:2014-10-07
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018056363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant