Provider Demographics
NPI:1104894724
Name:COLLEN, KIMBERLY ANN (PA)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:COLLEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:ANN
Other - Last Name:KOENIG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6 WELLNESS WAY STE 201
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2156
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:6 WELLNESS WAY STE 111
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-2156
Practice Address - Country:US
Practice Address - Phone:518-213-0227
Practice Address - Fax:518-782-3816
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005238-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS66739Medicare UPIN
NYBB2684Medicare ID - Type Unspecified