Basic Information
| Provider Information | |||||||||
| NPI: | 1073697694 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATTHIS | ||||||||
| FirstName: | KATHARINE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | RPA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 214 KING ST | ||||||||
| Address2: | |||||||||
| City: | OGDENSBURG | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136691142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153933600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 39 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136171358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153794700 | ||||||||
| FaxNumber: | 3157136512 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 03/22/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 006534 | NY | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 006534-1 | NY | N | Allopathic & Osteopathic Physicians | Family Medicine | 363AM0700X | 006534 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 01895252 | 05 | NY | MEDICAID |