Healthcare Provider Details

I. General information

NPI: 1952411928
Provider Name (Legal Business Name): KATHLEEN ANN O'CONNELL PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHLEEN ANN FLEMING PHYSICIAN ASSISTANT

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 08/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1445 PORTLAND AVENUE , SUITE 108
ROCHESTER NY
14621
US

IV. Provider business mailing address

1445 PORTLAND AVENUE , SUITE 108
ROCHESTER NY
14621
US

V. Phone/Fax

Practice location:
  • Phone: 585-922-5550
  • Fax: 585-922-5950
Mailing address:
  • Phone: 585-922-5550
  • Fax: 585-922-5950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number009482
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: