Provider Demographics
NPI:1245415843
Name:CALLAHAN, BRIAN (PA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:CALLAHAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 FARRELL RD
Mailing Address - Street 2:
Mailing Address - City:WILLSBORO
Mailing Address - State:NY
Mailing Address - Zip Code:12996-3904
Mailing Address - Country:US
Mailing Address - Phone:518-963-4275
Mailing Address - Fax:518-963-8862
Practice Address - Street 1:39 FARRELL RD
Practice Address - Street 2:
Practice Address - City:WILLSBORO
Practice Address - State:NY
Practice Address - Zip Code:12996-3904
Practice Address - Country:US
Practice Address - Phone:518-963-4275
Practice Address - Fax:518-963-8862
Is Sole Proprietor?:No
Enumeration Date:2008-01-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007116363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY007116OtherNYS LICENSE
NY007116OtherNYS LICENSE