Provider Demographics
NPI:1467691220
Name:ANNESSA, JOHN RAYMOND (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RAYMOND
Last Name:ANNESSA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4401 MIDDLE SETTLEMENT RD STE 102
Mailing Address - Street 2:
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413-5332
Mailing Address - Country:US
Mailing Address - Phone:315-735-4496
Mailing Address - Fax:
Practice Address - Street 1:4401 MIDDLE SETTLEMENT RD STE 102
Practice Address - Street 2:
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413-5332
Practice Address - Country:US
Practice Address - Phone:315-735-4496
Practice Address - Fax:315-735-7066
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-18
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008688363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1052954OtherTHE NATIONAL COMMISSION OF THE CERTIFICATION OF PHYSICIAN ASSISTANTS
NY008688OtherTHE UNIVERSITY OF THE STATE OF NEW YORK STATE EDUCATION DEPARTMENT