Provider Demographics
NPI:1114909892
Name:GOLIS, DENNIS (RPAC)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:
Last Name:GOLIS
Suffix:
Gender:M
Credentials:RPAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1729 BURRSTONE RD
Mailing Address - Street 2:
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413-1001
Mailing Address - Country:US
Mailing Address - Phone:318-798-1702
Mailing Address - Fax:315-798-1726
Practice Address - Street 1:1729 BURRSTONE RD
Practice Address - Street 2:
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413
Practice Address - Country:US
Practice Address - Phone:315-798-1617
Practice Address - Fax:315-624-1926
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011999363AS0400X
NY363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03974729Medicaid
P28292Medicare UPIN