Provider Demographics
NPI:1316464621
Name:TIVEY, KATELYN ANNE (PA-C)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:ANNE
Last Name:TIVEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3648 DEWEY AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14616-3024
Mailing Address - Country:US
Mailing Address - Phone:585-736-3503
Mailing Address - Fax:
Practice Address - Street 1:3648 DEWEY AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14616-3024
Practice Address - Country:US
Practice Address - Phone:585-736-3503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-28
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA6241207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine