Provider Demographics
NPI:1467488072
Name:O'SULLIVAN, KELLY (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:O'SULLIVAN
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 1:4278 COVENTRY GREEN CIR
Mailing Address - Street 2:DEPT OF MEDICINE
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-7237
Mailing Address - Country:US
Mailing Address - Phone:585-802-1510
Mailing Address - Fax:
Practice Address - Street 1:3 SILENT MEADOW LN
Practice Address - Street 2:DEPT OF MEDICINE
Practice Address - City:LANCASTER
Practice Address - State:NY
Practice Address - Zip Code:14086-3430
Practice Address - Country:US
Practice Address - Phone:716-391-0937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007841363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02426548Medicaid
NY02426548Medicaid
PA0015Medicare ID - Type UnspecifiedGROUP BA0017
DD1757Medicare ID - Type UnspecifiedGOUP70008A