Healthcare Provider Details

I. General information

NPI: 1013154566
Provider Name (Legal Business Name): KEVIN MAHONEY PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2009
Last Update Date: 11/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8411 SENECA TURNPIKE
NEW HARTFORD NY
13413-4308
US

IV. Provider business mailing address

2209 GENESEE STREET BUSINESS OFFICE
UTICA NY
13501-5930
US

V. Phone/Fax

Practice location:
  • Phone: 315-624-8500
  • Fax: 315-624-8515
Mailing address:
  • Phone: 315-801-3282
  • Fax: 315-801-8391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number013093-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: