Provider Demographics
NPI:1811933856
Name:HALCOMB, KELLY A (RPA C)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:A
Last Name:HALCOMB
Suffix:
Gender:F
Credentials:RPA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4855 CAMP RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HAMBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14075-2600
Mailing Address - Country:US
Mailing Address - Phone:716-646-1084
Mailing Address - Fax:716-646-0763
Practice Address - Street 1:4855 CAMP RD
Practice Address - Street 2:SUITE 100
Practice Address - City:HAMBURG
Practice Address - State:NY
Practice Address - Zip Code:14075-2600
Practice Address - Country:US
Practice Address - Phone:716-646-1084
Practice Address - Fax:716-646-0763
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2014-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010492363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02651090Medicaid
NY02651090Medicaid
NYPA0736Medicare PIN
NYP00648682Medicare PIN