Provider Demographics
NPI:1013418540
Name:KOLB, MICHAEL DAVID (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:KOLB
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:549 GREEN PL
Mailing Address - Street 2:
Mailing Address - City:WOODMERE
Mailing Address - State:NY
Mailing Address - Zip Code:11598-1908
Mailing Address - Country:US
Mailing Address - Phone:201-575-6945
Mailing Address - Fax:
Practice Address - Street 1:549 GREEN PL
Practice Address - Street 2:
Practice Address - City:WOODMERE
Practice Address - State:NY
Practice Address - Zip Code:11598-1908
Practice Address - Country:US
Practice Address - Phone:201-575-6945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-21
Last Update Date:2018-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant