Basic Information
| Provider Information | |||||||||
| NPI: | 1932140381 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOLMETZ | ||||||||
| FirstName: | MELODIE | ||||||||
| MiddleName: | JOY | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ENEDY | ||||||||
| OtherFirstName: | MELODIE | ||||||||
| OtherMiddleName: | JOY | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1870 WINTON RD S | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146183960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852760830 | ||||||||
| FaxNumber: | 5854244184 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 HAHNEMANN TRL | ||||||||
| Address2: | |||||||||
| City: | PITTSFORD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 145342356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853890988 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 10/06/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 005322 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AM0700X | 005322 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 005322 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 000918016002 | 01 | HEALTH NOW | OTHER | 108964BF | 01 | PREFERRED CARE | OTHER | MK5617610 | 01 | DEA | OTHER | P019005322 | 01 | EXCELLUS PLANS | OTHER |