Provider Demographics
NPI:1932140381
Name:KOLMETZ, MELODIE JOY (PA)
Entity Type:Individual
Prefix:MS
First Name:MELODIE
Middle Name:JOY
Last Name:KOLMETZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:MELODIE
Other - Middle Name:JOY
Other - Last Name:ENEDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1870 WINTON RD S
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-3960
Mailing Address - Country:US
Mailing Address - Phone:585-276-0830
Mailing Address - Fax:585-424-4184
Practice Address - Street 1:500 HAHNEMANN TRL
Practice Address - Street 2:
Practice Address - City:PITTSFORD
Practice Address - State:NY
Practice Address - Zip Code:14534-2356
Practice Address - Country:US
Practice Address - Phone:585-389-0988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005322363A00000X, 363AS0400X, 363AM0700X
NY5322363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P019005322OtherEXCELLUS PLANS
000918016002OtherHEALTH NOW
108964BFOtherPREFERRED CARE
P019005322OtherEXCELLUS PLANS
PA0006Medicare ID - Type Unspecified