Provider Demographics
NPI:1992145601
Name:MONAHAN, MEREDYTH L (PA)
Entity type:Individual
Prefix:
First Name:MEREDYTH
Middle Name:L
Last Name:MONAHAN
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 1:121 EVERETT RD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205-1474
Mailing Address - Country:US
Mailing Address - Phone:518-489-2663
Mailing Address - Fax:518-689-6881
Practice Address - Street 1:121 EVERETT RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-1474
Practice Address - Country:US
Practice Address - Phone:518-489-2663
Practice Address - Fax:518-689-6881
Is Sole Proprietor?:No
Enumeration Date:2013-06-26
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016590363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY016590OtherNY LICENSE
NY03786330Medicaid