Provider Demographics
NPI:1447539507
Name:MACK, KRISTIN L (DO)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:L
Last Name:MACK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:MICHELLE
Other - Last Name:LAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9 CAREY RD
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-7880
Mailing Address - Country:US
Mailing Address - Phone:518-761-0300
Mailing Address - Fax:518-824-2388
Practice Address - Street 1:101 ADIRONDACK DR STE 2
Practice Address - Street 2:
Practice Address - City:TICONDEROGA
Practice Address - State:NY
Practice Address - Zip Code:12883-9334
Practice Address - Country:US
Practice Address - Phone:518-585-6708
Practice Address - Fax:518-585-3260
Is Sole Proprietor?:No
Enumeration Date:2011-08-08
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY272786207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03861103Medicaid
NY5112971OtherAETNA
NY03861103Medicaid
NY03861103Medicaid