Provider Demographics
NPI:1538424361
Name:BENNETT, KATHLEEN GARBARINO (PA)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:GARBARINO
Last Name:BENNETT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:MARIE
Other - Last Name:GARBARINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:711 TROY SCHENECTADY RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2442
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:1783 ROUTE 9
Practice Address - Street 2:SUITE 101
Practice Address - City:HALFMOON
Practice Address - State:NY
Practice Address - Zip Code:12065-2409
Practice Address - Country:US
Practice Address - Phone:518-371-5437
Practice Address - Fax:518-383-6737
Is Sole Proprietor?:No
Enumeration Date:2012-07-09
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015873363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03494084Medicaid
NY121107000022OtherFIDELIS CARE NY
NY03494084Medicaid