Provider Demographics
NPI:1265273635
Name:EMERSON, KELLY ALICE (PA-C)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:ALICE
Last Name:EMERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7823 HAYES HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:COLDEN
Mailing Address - State:NY
Mailing Address - Zip Code:14033-9776
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:77 GOODELL ST STE 340
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-1243
Practice Address - Country:US
Practice Address - Phone:716-645-9715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-01
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X, 390200000X
NY032417363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program