Provider Demographics
NPI:1518342088
Name:EMMERT, KELLY R (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:R
Last Name:EMMERT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:RENEE
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:125 MINEOLA AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ROSLYN HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11577-2023
Mailing Address - Country:US
Mailing Address - Phone:516-616-5500
Mailing Address - Fax:888-502-6585
Practice Address - Street 1:125 MINEOLA AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:ROSLYN HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11577-2023
Practice Address - Country:US
Practice Address - Phone:516-616-5500
Practice Address - Fax:888-502-6585
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-27
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018867363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical