Healthcare Provider Details

I. General information

NPI: 1801868005
Provider Name (Legal Business Name): PATRICK CORNELIUS KEARNEY PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: PADRAIG CORNELIUS KEARNEY PA-C

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 11/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 PARK AVE
WILLISTON VT
05495-9701
US

IV. Provider business mailing address

28 PARK AVE PRIMARY CARE
WILLISTON VT
05495-9701
US

V. Phone/Fax

Practice location:
  • Phone: 802-878-1008
  • Fax: 802-872-2679
Mailing address:
  • Phone: 802-878-1008
  • Fax: 802-872-2679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number055-0030829
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number055-0030968
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: