Provider Demographics
NPI:1518639566
Name:GRIGGS, KELLY (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:GRIGGS
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 1:24 SPICE MILL BLVD
Mailing Address - Street 2:
Mailing Address - City:HALFMOON
Mailing Address - State:NY
Mailing Address - Zip Code:12065-2638
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12204-1004
Practice Address - Country:US
Practice Address - Phone:518-471-3221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-29
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant