Provider Demographics
NPI:1154908390
Name:HORAN, MARY KATHRYN (PA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHRYN
Last Name:HORAN
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 1:10 ROBIN RD
Mailing Address - Street 2:
Mailing Address - City:DIX HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11746-7810
Mailing Address - Country:US
Mailing Address - Phone:631-525-7318
Mailing Address - Fax:
Practice Address - Street 1:500 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-4418
Practice Address - Country:US
Practice Address - Phone:631-422-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-25
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026500363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant