Provider Demographics
NPI:1235318833
Name:MATHESON, MICHELLE MARIA (PA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARIA
Last Name:MATHESON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:33 LEWIS RD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905
Mailing Address - Country:US
Mailing Address - Phone:607-729-8156
Mailing Address - Fax:607-729-3982
Practice Address - Street 1:30 HARRISON ST STE 455
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2176
Practice Address - Country:US
Practice Address - Phone:607-763-8100
Practice Address - Fax:607-763-8048
Is Sole Proprietor?:No
Enumeration Date:2007-10-31
Last Update Date:2022-07-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY012040208M00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03236537Medicaid