Provider Demographics
NPI:1457933780
Name:O'CONNOR, KAITLIN
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:
Last Name:O'CONNOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270-05 76TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040
Mailing Address - Country:US
Mailing Address - Phone:631-617-4033
Mailing Address - Fax:
Practice Address - Street 1:270-05 76TH AVE
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040
Practice Address - Country:US
Practice Address - Phone:708-470-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-26
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NY026440207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery