Provider Demographics
NPI:1356575369
Name:MEYER, KELLY (PA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MEYER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 FEATHERS DRIVE
Mailing Address - Street 2:CHAMPLAIN SPINE & PAIN MANAGEMENT
Mailing Address - City:PLATTSBUGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-0641
Mailing Address - Country:US
Mailing Address - Phone:183-247-2465
Mailing Address - Fax:518-324-3366
Practice Address - Street 1:4 FEATHERS DRIVE
Practice Address - Street 2:CHAMPLAIN SPINE & PAIN MANAGEMENT
Practice Address - City:PLATTSBUGH
Practice Address - State:NY
Practice Address - Zip Code:12901-0641
Practice Address - Country:US
Practice Address - Phone:183-247-2465
Practice Address - Fax:518-324-3366
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-05
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY013334363A00000X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical