Provider Demographics
NPI:1437191277
Name:TIERNAN, STEVEN D (PA)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:D
Last Name:TIERNAN
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 1:1575 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-9371
Mailing Address - Country:US
Mailing Address - Phone:315-786-7300
Mailing Address - Fax:315-786-7310
Practice Address - Street 1:22670 SUMMIT DR
Practice Address - Street 2:STE 3
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-7208
Practice Address - Country:US
Practice Address - Phone:315-755-2560
Practice Address - Fax:315-755-2597
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009062363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03731160Medicaid
NY00354316Medicaid
P77232Medicare UPIN