Provider Demographics
NPI:1922034404
Name:MATTHYS, KRISTIN MARIELLE (PT)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:MARIELLE
Last Name:MATTHYS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:MARIELLE
Other - Last Name:NETHERCOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:101 PALMER DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-1242
Mailing Address - Country:US
Mailing Address - Phone:315-637-4747
Mailing Address - Fax:315-637-4747
Practice Address - Street 1:4279 CRESTED BUTTE RUN
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13215-1355
Practice Address - Country:US
Practice Address - Phone:315-569-9308
Practice Address - Fax:315-295-2579
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0115671225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000921740001OtherHEALTHNOW NY
NY5056028OtherAETNA
NY435174OtherMVP
NY000135080OtherBSCNY
NY161303109OtherUNITED HEALTHCARE
NYAA1220OtherMEDICARE
NY161303109OtherCIGNA
NY000921740001OtherHEALTHNOW NY