Provider Demographics
NPI:1588140107
Name:HAM, KATHRYN ELIZABETH (PA)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ELIZABETH
Last Name:HAM
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 1:1061 STOLL CT
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-1409
Mailing Address - Country:US
Mailing Address - Phone:910-935-0036
Mailing Address - Fax:
Practice Address - Street 1:117 MARYS AVE STE 101
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-5849
Practice Address - Country:US
Practice Address - Phone:845-339-1515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-17
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022184-1363A00000X
NY022184363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant