Healthcare Provider Details

I. General information

NPI: 1639741846
Provider Name (Legal Business Name): KRISTIN ROSE MCDONOUGH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2021
Last Update Date: 11/10/2023
Certification Date: 11/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 E OLD COUNTRY RD
HICKSVILLE NY
11801-4293
US

IV. Provider business mailing address

1 ATLANTIC AVE APT 78
FARMINGDALE NY
11735-2772
US

V. Phone/Fax

Practice location:
  • Phone: 169-876-4285
  • Fax:
Mailing address:
  • Phone: 631-560-5861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number026791
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number026791
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: