Provider Demographics
NPI:1043846520
Name:KEARNEY, CAROLINE HANNAH (PA-C)
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:HANNAH
Last Name:KEARNEY
Suffix:
Gender:F
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:PO BOX 933432
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-0039
Mailing Address - Country:US
Mailing Address - Phone:937-641-5072
Mailing Address - Fax:937-641-6129
Practice Address - Street 1:1 CHILDRENS PLZ
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45404-1815
Practice Address - Country:US
Practice Address - Phone:937-641-3600
Practice Address - Fax:937-641-5802
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-17
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA062236363A00000X
OH50.007890RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0016184Medicaid
PAMA062236OtherPA LICENSE
PAOA005506OtherOA LICENSE