1417668773 NPI number — KRISTA M. GAETANO

Table of content: KRISTA M. GAETANO (NPI 1417668773)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417668773 NPI number — KRISTA M. GAETANO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GAETANO
Provider First Name:
KRISTA
Provider Middle Name:
M.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417668773
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/07/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 376
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CROMPOND
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10517-0376
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
914-673-2342
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
519 UNION AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEEKSKILL
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10566-4706
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
646-799-6312
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/07/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 343900000X , with the licence number:  05592425 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 05592425 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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