Provider Demographics
NPI:1336260157
Name:KHOURY, THERESE M (RPA-C)
Entity type:Individual
Prefix:MS
First Name:THERESE
Middle Name:M
Last Name:KHOURY
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 ATRIUM DR STE 100
Mailing Address - Street 2:ATTN TAMMY M. BUTTON
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205-1441
Mailing Address - Country:US
Mailing Address - Phone:518-435-2740
Mailing Address - Fax:518-458-2610
Practice Address - Street 1:4 PALISADES DR
Practice Address - Street 2:SUITE 100
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-1443
Practice Address - Country:US
Practice Address - Phone:518-446-9545
Practice Address - Fax:518-446-9551
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006673363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPA1729Medicare PIN
NYS80934Medicare UPIN