Basic Information
| Provider Information | |||||||||
| NPI: | 1386622090 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOLD | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | JOAN | ||||||||
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| Credential: | ANP EDD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 346 GRAND AVE | ||||||||
| Address2: | UNITED MEDICAL ASSOCAITES PC | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 137902558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077700025 | ||||||||
| FaxNumber: | 6077293982 | ||||||||
| Practice Location | |||||||||
| Address1: | 33-57 HARRISON ST | ||||||||
| Address2: | HOSPITALIST PROGRAM - TCU | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 137902107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077636622 | ||||||||
| FaxNumber: | 6077635064 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2006 | ||||||||
| LastUpdateDate: | 01/29/2009 | ||||||||
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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 | 363L00000X | F301130 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2200X | F301130 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 02463156 | 05 | NY | MEDICAID |