Provider Demographics
NPI:1346397692
Name:BRIODY, KATHLEEN M (PA)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:BRIODY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 HOSPITAL RD.
Mailing Address - Street 2:
Mailing Address - City:OAK BLUFFS
Mailing Address - State:MA
Mailing Address - Zip Code:02557
Mailing Address - Country:US
Mailing Address - Phone:508-693-0410
Mailing Address - Fax:
Practice Address - Street 1:1 HOSPITAL RD.
Practice Address - Street 2:
Practice Address - City:OAK BLUFFS
Practice Address - State:MA
Practice Address - Zip Code:02557
Practice Address - Country:US
Practice Address - Phone:508-693-0410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2016-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0003434363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P31611Medicare UPIN
460LQ890Medicare PIN