Provider Demographics
NPI:1801868005
Name:KEARNEY, PATRICK CORNELIUS (PA)
Entity Type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:CORNELIUS
Last Name:KEARNEY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:PADRAIG
Other - Middle Name:CORNELIUS
Other - Last Name:KEARNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:28 PARK AVE
Mailing Address - Street 2:PRIMARY CARE
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-9701
Mailing Address - Country:US
Mailing Address - Phone:802-878-1008
Mailing Address - Fax:802-872-2679
Practice Address - Street 1:28 PARK AVE
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495-9701
Practice Address - Country:US
Practice Address - Phone:802-878-1008
Practice Address - Fax:802-872-2679
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT055-0030829363A00000X
VT055-0030968363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT9000255Medicaid
AP260801OtherMEDICARE PTAN