Provider Demographics
NPI:1780952861
Name:CALLAHAN, KELLY J (PA-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:CALLAHAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:J
Other - Last Name:MALEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 PARK ST
Mailing Address - Street 2:
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-4447
Mailing Address - Country:US
Mailing Address - Phone:518-926-5924
Mailing Address - Fax:518-926-6983
Practice Address - Street 1:100 PARK ST
Practice Address - Street 2:
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-4447
Practice Address - Country:US
Practice Address - Phone:518-926-5925
Practice Address - Fax:518-926-5917
Is Sole Proprietor?:No
Enumeration Date:2011-12-05
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015348363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03432579Medicaid
NY03432579Medicaid