Provider Demographics
NPI:1528195260
Name:JOLY, KATHLEEN BRIDGET (MS, RPA-C)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:BRIDGET
Last Name:JOLY
Suffix:
Gender:F
Credentials:MS, RPA-C
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:BRIDGET
Other - Last Name:GUYDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:125 BUSINESS PARK DR
Mailing Address - Street 2:SUITE 150
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-6304
Mailing Address - Country:US
Mailing Address - Phone:315-235-2540
Mailing Address - Fax:315-235-2171
Practice Address - Street 1:125 BUSINESS PARK DR
Practice Address - Street 2:SUITE 150
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-6304
Practice Address - Country:US
Practice Address - Phone:315-235-2540
Practice Address - Fax:315-235-2171
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011751-1363A00000X
NY011751363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400005300Medicare PIN