Provider Demographics
NPI:1952471187
Name:BOLAN, KEVIN P (RPA C)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:P
Last Name:BOLAN
Suffix:
Gender:M
Credentials:RPA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 SANTANONI DRIVE
Mailing Address - Street 2:
Mailing Address - City:NEWCOMB
Mailing Address - State:NY
Mailing Address - Zip Code:12852-1913
Mailing Address - Country:US
Mailing Address - Phone:518-582-2991
Mailing Address - Fax:518-582-2040
Practice Address - Street 1:4 SANTANONI DRIVE
Practice Address - Street 2:
Practice Address - City:NEWCOMB
Practice Address - State:NY
Practice Address - Zip Code:12852
Practice Address - Country:US
Practice Address - Phone:518-582-2991
Practice Address - Fax:518-582-2040
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0022961363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01110874Medicaid
NY53283CMedicare PIN
NYR88670Medicare UPIN
NY53283AMedicare PIN