=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144056243
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EMMA KATE MCKEAN STUDENT (PA-S)
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2024
-----------------------------------------------------
Last Update Date | 03/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 701 N BROADWAY
-----------------------------------------------------
City | SLEEPY HOLLOW
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10591-1020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-416-4426
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18 DEBBIE LEE LN
-----------------------------------------------------
City | BOHEMIA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11716-3803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-416-4426
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 033289-01
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------