Provider Demographics
NPI:1053480244
Name:TICHENOR, LOUISE L (PA)
Entity Type:Individual
Prefix:
First Name:LOUISE
Middle Name:L
Last Name:TICHENOR
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 1:336 ELM ST
Mailing Address - Street 2:
Mailing Address - City:MALONE
Mailing Address - State:NY
Mailing Address - Zip Code:12953-1514
Mailing Address - Country:US
Mailing Address - Phone:518-483-0022
Mailing Address - Fax:518-483-6179
Practice Address - Street 1:336 ELM ST
Practice Address - Street 2:
Practice Address - City:MALONE
Practice Address - State:NY
Practice Address - Zip Code:12953-1514
Practice Address - Country:US
Practice Address - Phone:518-483-0022
Practice Address - Fax:518-483-6179
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4851577363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01916090Medicaid
NY01916090Medicaid