Basic Information
| Provider Information | |||||||||
| NPI: | 1225385305 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KENNY | ||||||||
| FirstName: | KATIE | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1555 LONG POND ROAD | ||||||||
| Address2: | DEPARTMENT OF SURGERY | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146264122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5857237225 | ||||||||
| FaxNumber: | 5857237280 | ||||||||
| Practice Location | |||||||||
| Address1: | 1555 LONG POND RD FL 1 | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146264122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5857237000 | ||||||||
| FaxNumber: | 5857237280 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2012 | ||||||||
| LastUpdateDate: | 06/26/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 015698 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 03524476 | 05 | NY | MEDICAID | 12434137 | 01 | NY | CAQH | OTHER |