Provider Demographics
NPI:1205884293
Name:KOENIG, KARLEEN (PA)
Entity type:Individual
Prefix:
First Name:KARLEEN
Middle Name:
Last Name:KOENIG
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 1:20 GRAND ST
Mailing Address - Street 2:FL 3
Mailing Address - City:WARWICK
Mailing Address - State:NY
Mailing Address - Zip Code:10990-1035
Mailing Address - Country:US
Mailing Address - Phone:845-368-5000
Mailing Address - Fax:845-987-5979
Practice Address - Street 1:100 E 77TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-1850
Practice Address - Country:US
Practice Address - Phone:212-434-2650
Practice Address - Fax:212-434-4512
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004574363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02044200Medicaid
S98252Medicare UPIN
NY0F54723051Medicare ID - Type Unspecified