Provider Demographics
NPI:1326303678
Name:REILLY, KERRY K (PA)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:K
Last Name:REILLY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:315 S MANNING BLVD
Mailing Address - Street 2:RM 1677
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-1789
Mailing Address - Country:US
Mailing Address - Phone:518-525-1550
Mailing Address - Fax:518-525-1722
Practice Address - Street 1:315 S MANNING BLVD
Practice Address - Street 2:RM 1677
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-1789
Practice Address - Country:US
Practice Address - Phone:518-525-1550
Practice Address - Fax:518-525-1722
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-11
Last Update Date:2012-08-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY015825363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical