Provider Demographics
NPI:1952411928
Name:O'CONNELL, KATHLEEN ANN (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:ANN
Last Name:O'CONNELL
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:MS
Other - First Name:KATHLEEN
Other - Middle Name:ANN
Other - Last Name:FLEMING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHYSICIAN ASSISTANT
Mailing Address - Street 1:1445 PORTLAND AVENUE , SUITE 108
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621
Mailing Address - Country:US
Mailing Address - Phone:585-922-5550
Mailing Address - Fax:585-922-5950
Practice Address - Street 1:1445 PORTLAND AVENUE , SUITE 108
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621
Practice Address - Country:US
Practice Address - Phone:585-922-5550
Practice Address - Fax:585-922-5950
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009482363AM0700X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292385800Medicaid
FLPA0104Medicare ID - Type Unspecified
FLQ06068Medicare UPIN