Provider Demographics
NPI:1215277793
Name:DIPERNA, KAITLYN ELIZABETH (PA-C)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:ELIZABETH
Last Name:DIPERNA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KAITLYN
Other - Middle Name:ELIZABETH
Other - Last Name:WIGGINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:571 SAINT JOSEPHS BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-3230
Mailing Address - Country:US
Mailing Address - Phone:607-271-2050
Mailing Address - Fax:607-873-1244
Practice Address - Street 1:418 S HAMILTON ST # 109
Practice Address - Street 2:
Practice Address - City:PAINTED POST
Practice Address - State:NY
Practice Address - Zip Code:14870-9705
Practice Address - Country:US
Practice Address - Phone:607-936-2089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-21
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021197363A00000X
GA7570363A00000X
TN2278363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04925375Medicaid