Provider Demographics
NPI:1902891930
Name:CALLAGHAN, OLIN P (PA)
Entity Type:Individual
Prefix:MR
First Name:OLIN
Middle Name:P
Last Name:CALLAGHAN
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:
Practice Address - Street 1:250 DELAWARE AVE STE 100
Practice Address - Street 2:
Practice Address - City:DELMAR
Practice Address - State:NY
Practice Address - Zip Code:12054-1402
Practice Address - Country:US
Practice Address - Phone:518-439-8077
Practice Address - Fax:518-439-8070
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009711363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPA0940Medicare ID - Type Unspecified
Q21295Medicare UPIN
NYPA2394Medicare PIN