Provider Demographics
NPI:1164510913
Name:DEGONZAGUE, KIRSTEN HAMILTON (DC)
Entity type:Individual
Prefix:DR
First Name:KIRSTEN
Middle Name:HAMILTON
Last Name:DEGONZAGUE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:KIRSTEN
Other - Middle Name:ANN
Other - Last Name:HAMILTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:44 SWARTSON CT
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12209-1237
Mailing Address - Country:US
Mailing Address - Phone:518-489-0963
Mailing Address - Fax:
Practice Address - Street 1:344 FULLER RD
Practice Address - Street 2:INNER BALANCE CHIROPRACTIC
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-3647
Practice Address - Country:US
Practice Address - Phone:518-482-2003
Practice Address - Fax:518-482-2087
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX009755-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY10095460OtherCDPHP PROVIDER NUMBER
NYCO9755-2OtherWORKER COMP
NYU83271Medicare UPIN
NYCC3964Medicare ID - Type Unspecified