Provider Demographics
NPI:1194788372
Name:DOLLARD, MICHAEL A (PA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:DOLLARD
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 TROY SCHENECTADY RD STE 203
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2461
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:1240 NEW SCOTLAND RD
Practice Address - Street 2:SUITE 203
Practice Address - City:SLINGERLANDS
Practice Address - State:NY
Practice Address - Zip Code:12159-9222
Practice Address - Country:US
Practice Address - Phone:518-439-2460
Practice Address - Fax:518-439-3025
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006652363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY080925000085OtherFIDELIS
NY6019908OtherMVP HEALTHCARE
NY10040637OtherCDPHP
NY000495200004OtherBSNENY
NY03027016Medicaid
NY6019908OtherMVP HEALTHCARE