Provider Demographics
NPI:1972842151
Name:RONAN, ALISHA L (PA)
Entity Type:Individual
Prefix:
First Name:ALISHA
Middle Name:L
Last Name:RONAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:711 TROY SCHENECTADY RD STE 203
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2461
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:100 GREAT OAKS BLVD
Practice Address - Street 2:SUITE 105
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-7924
Practice Address - Country:US
Practice Address - Phone:518-869-8007
Practice Address - Fax:518-869-8742
Is Sole Proprietor?:No
Enumeration Date:2013-02-07
Last Update Date:2018-01-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY016365363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
130408000105OtherFIDELIS CARE NY
NY03541742Medicaid
130408000105OtherFIDELIS CARE NY