Provider Demographics
NPI:1386622090
Name:WOLD, KATHLEEN JOAN (ANP EDD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:JOAN
Last Name:WOLD
Suffix:
Gender:F
Credentials:ANP EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:346 GRAND AVE
Mailing Address - Street 2:UNITED MEDICAL ASSOCAITES PC
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2558
Mailing Address - Country:US
Mailing Address - Phone:607-770-0025
Mailing Address - Fax:607-729-3982
Practice Address - Street 1:33-57 HARRISON ST
Practice Address - Street 2:HOSPITALIST PROGRAM - TCU
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2107
Practice Address - Country:US
Practice Address - Phone:607-763-6622
Practice Address - Fax:607-763-5064
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF301130363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02463156Medicaid
BB1465Medicare ID - Type Unspecified