Basic Information
Provider Information | |||||||||
NPI: | 1255595641 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HUESTIS | ||||||||
FirstName: | KATHLEEN | ||||||||
MiddleName: | P | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PANGIA | ||||||||
OtherFirstName: | KATHLEEN | ||||||||
OtherMiddleName: | ANN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 9 CAREY RD | ||||||||
Address2: |   | ||||||||
City: | QUEENSBURY | ||||||||
State: | NY | ||||||||
PostalCode: | 128047880 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5187610300 | ||||||||
FaxNumber: | 5188242388 | ||||||||
Practice Location | |||||||||
Address1: | 102 RACE TRACK RD | ||||||||
Address2: |   | ||||||||
City: | TICONDEROGA | ||||||||
State: | NY | ||||||||
PostalCode: | 128834004 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5185856708 | ||||||||
FaxNumber: | 5185853260 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/15/2008 | ||||||||
LastUpdateDate: | 02/07/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 257880 | NY | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 03255272 | 05 | NY |   | MEDICAID |