Basic Information
| Provider Information | |||||||||
| NPI: | 1245960673 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | CAROLINE | ||||||||
| MiddleName: | MARY | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21 COBBLE HILL DR | ||||||||
| Address2: | |||||||||
| City: | GANSEVOORT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128312525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187797428 | ||||||||
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| Practice Location | |||||||||
| Address1: | 211 CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | SARATOGA SPRINGS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128661003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185873222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2022 | ||||||||
| LastUpdateDate: | 06/17/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.