Provider Demographics
NPI:1902852742
Name:CULTRARA, KATHERINE TANNER (PNP)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:TANNER
Last Name:CULTRARA
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 14890
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12212-4890
Mailing Address - Country:US
Mailing Address - Phone:518-525-5634
Mailing Address - Fax:518-649-4094
Practice Address - Street 1:1240 NEW SCOTLAND RD
Practice Address - Street 2:SUITE 100
Practice Address - City:SLINGERLANDS
Practice Address - State:NY
Practice Address - Zip Code:12159-9222
Practice Address - Country:US
Practice Address - Phone:518-475-7000
Practice Address - Fax:518-474-7050
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF380358363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01878477Medicaid
NY01878477Medicaid
NYBB8777Medicare ID - Type Unspecified