=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821720939
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MOLLY LYNNE COOLICAN PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2022
-----------------------------------------------------
Last Update Date | 08/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 SENECA ST STE 4
-----------------------------------------------------
City | ONEIDA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13421-2743
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-363-1345
-----------------------------------------------------
Fax | 315-363-9243
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6111 DUNBARTON RD
-----------------------------------------------------
City | DURHAMVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13054-3197
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-832-8649
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QA0505X
-----------------------------------------------------
Taxonomy Name | Adult Medicine Physician
-----------------------------------------------------
License Number | 030994
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------