Healthcare Provider Details

I. General information

NPI: 1528596293
Provider Name (Legal Business Name): KATHARINE LYNN KURTZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2017
Last Update Date: 12/10/2019
Certification Date: 12/10/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 PORTLAND AVE
ROCHESTER NY
14621-3011
US

IV. Provider business mailing address

243 MOSLEY DR
SYRACUSE NY
13206-2336
US

V. Phone/Fax

Practice location:
  • Phone: 585-338-1200
  • Fax: 585-544-1359
Mailing address:
  • Phone: 719-492-8088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number021459
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: