Provider Demographics
NPI:1013154566
Name:MAHONEY, KEVIN (PA)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:MAHONEY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:2209 GENESEE STREET
Mailing Address - Street 2:BUSINESS OFFICE
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-5930
Mailing Address - Country:US
Mailing Address - Phone:315-801-3282
Mailing Address - Fax:315-801-8391
Practice Address - Street 1:8411 SENECA TURNPIKE
Practice Address - Street 2:
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413-4308
Practice Address - Country:US
Practice Address - Phone:315-624-8500
Practice Address - Fax:315-624-8515
Is Sole Proprietor?:No
Enumeration Date:2009-01-20
Last Update Date:2018-11-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY013093-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03434035Medicaid