Provider Demographics
NPI:1801398037
Name:KOLODGIE, KEVIN PAUL
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:PAUL
Last Name:KOLODGIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 E FRONT ST APT 3
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16507-1682
Mailing Address - Country:US
Mailing Address - Phone:570-540-0521
Mailing Address - Fax:
Practice Address - Street 1:4320 SEMINARY RD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304
Practice Address - Country:US
Practice Address - Phone:703-504-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-04
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN627040367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered