Provider Demographics
NPI:1942625702
Name:KOTAK, KRISTEN MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:MARIE
Last Name:KOTAK
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 1:193 BALTIMORE AVE
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-4229
Mailing Address - Country:US
Mailing Address - Phone:516-395-8767
Mailing Address - Fax:
Practice Address - Street 1:193 BALTIMORE AVE
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-4229
Practice Address - Country:US
Practice Address - Phone:516-395-8767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-03
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017420363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant