Provider Demographics
NPI:1194141564
Name:HUNTLEY, KATHLEEN (PA)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:HUNTLEY
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 1:200 GARDEN CITY PLZ
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-3301
Mailing Address - Country:US
Mailing Address - Phone:516-663-6400
Mailing Address - Fax:516-663-6401
Practice Address - Street 1:200 GARDEN CITY PLZ
Practice Address - Street 2:SUITE 100
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-3301
Practice Address - Country:US
Practice Address - Phone:516-663-6400
Practice Address - Fax:516-663-6401
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-10
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017161363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant