Basic Information
Provider Information | |||||||||
NPI: | 1255767752 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MONACO | ||||||||
FirstName: | EMILY | ||||||||
MiddleName: | BEATTY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BEATTY | ||||||||
OtherFirstName: | EMILY | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 9 CAREY RD | ||||||||
Address2: |   | ||||||||
City: | QUEENSBURY | ||||||||
State: | NY | ||||||||
PostalCode: | 128047880 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5187610300 | ||||||||
FaxNumber: | 5188242388 | ||||||||
Practice Location | |||||||||
Address1: | 2249 STATE ROUTE 86 STE 3 | ||||||||
Address2: |   | ||||||||
City: | SARANAC LAKE | ||||||||
State: | NY | ||||||||
PostalCode: | 129835646 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5188913845 | ||||||||
FaxNumber: | 5188911236 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/17/2013 | ||||||||
LastUpdateDate: | 04/05/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/05/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 023918 | NY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 06150036 | 05 | NY |   | MEDICAID |