1801868005 NPI number — MR. PATRICK CORNELIUS KEARNEY PA

Table of content: AMBER BARKER (NPI 1508258047)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801868005 NPI number — MR. PATRICK CORNELIUS KEARNEY PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KEARNEY
Provider First Name:
PATRICK
Provider Middle Name:
CORNELIUS
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KEARNEY
Provider Other First Name:
PADRAIG
Provider Other Middle Name:
CORNELIUS
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1801868005
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/25/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
28 PARK AVE
Provider Second Line Business Mailing Address:
PRIMARY CARE
Provider Business Mailing Address City Name:
WILLISTON
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05495-9701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-878-1008
Provider Business Mailing Address Fax Number:
802-872-2679

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
28 PARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILLISTON
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05495-9701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-878-1008
Provider Business Practice Location Address Fax Number:
802-872-2679
Provider Enumeration Date:
02/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  055-0030829 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X , with the licence number: 055-0030968 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9000255 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: AP260801 . This is a "MEDICARE PTAN" identifier . This identifiers is of the category "OTHER".




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