Basic Information
| Provider Information | |||||||||
| NPI: | 1194788372 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOLLARD | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 711 TROY SCHENECTADY RD STE 203 | ||||||||
| Address2: | |||||||||
| City: | LATHAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121102461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187823700 | ||||||||
| FaxNumber: | 5187823799 | ||||||||
| Practice Location | |||||||||
| Address1: | 1240 NEW SCOTLAND RD | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | SLINGERLANDS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121599222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5184392460 | ||||||||
| FaxNumber: | 5184393025 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2006 | ||||||||
| LastUpdateDate: | 01/25/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 006652 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 080925000085 | 01 | NY | FIDELIS | OTHER | 6019908 | 01 | NY | MVP HEALTHCARE | OTHER | 10040637 | 01 | NY | CDPHP | OTHER | 000495200004 | 01 | NY | BSNENY | OTHER | 03027016 | 05 | NY | MEDICAID |