Provider Demographics
NPI:1255595641
Name:HUESTIS, KATHLEEN P (MD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:P
Last Name:HUESTIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:ANN
Other - Last Name:PANGIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:9 CAREY RD
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-7880
Mailing Address - Country:US
Mailing Address - Phone:518-761-0300
Mailing Address - Fax:518-824-2388
Practice Address - Street 1:102 RACE TRACK RD
Practice Address - Street 2:
Practice Address - City:TICONDEROGA
Practice Address - State:NY
Practice Address - Zip Code:12883-4004
Practice Address - Country:US
Practice Address - Phone:518-585-6708
Practice Address - Fax:518-585-3260
Is Sole Proprietor?:No
Enumeration Date:2008-07-15
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY257880207Q00000X
PAMT184276207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03255272Medicaid
NY03255272Medicaid