Provider Demographics
NPI:1164424362
Name:PECK, CHRISTOPHER L (PA)
Entity Type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:L
Last Name:PECK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:4364 LOWER COVERT RD
Mailing Address - Street 2:
Mailing Address - City:TRUMANSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14886-9305
Mailing Address - Country:US
Mailing Address - Phone:607-273-3161
Mailing Address - Fax:607-273-4979
Practice Address - Street 1:1301 TRUMANSBURG RD
Practice Address - Street 2:STE E
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1397
Practice Address - Country:US
Practice Address - Phone:607-273-3161
Practice Address - Fax:607-273-4979
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY002559363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2504263Medicaid
NYDD4334Medicare ID - Type Unspecified
NYR55980Medicare UPIN