Provider Demographics
NPI:1255918355
Name:MAGNER, KATHLEEN JACQUELINE (DO)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:JACQUELINE
Last Name:MAGNER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205A VAN AERNEM RD
Mailing Address - Street 2:
Mailing Address - City:BALLSTON SPA
Mailing Address - State:NY
Mailing Address - Zip Code:12020-3803
Mailing Address - Country:US
Mailing Address - Phone:201-230-1877
Mailing Address - Fax:
Practice Address - Street 1:510 GEYSER RD
Practice Address - Street 2:
Practice Address - City:BALLSTON SPA
Practice Address - State:NY
Practice Address - Zip Code:12020-3007
Practice Address - Country:US
Practice Address - Phone:518-289-2720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-25
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY331819207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY331819OtherLICENSE NUMBER