Provider Demographics
NPI:1477003416
Name:THUJA, MATTHEW (PA-C)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:THUJA
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:PO BOX 423
Mailing Address - Street 2:
Mailing Address - City:PENN YAN
Mailing Address - State:NY
Mailing Address - Zip Code:14527-0423
Mailing Address - Country:US
Mailing Address - Phone:315-531-9102
Mailing Address - Fax:315-531-9103
Practice Address - Street 1:7150 MAIN ST
Practice Address - Street 2:
Practice Address - City:OVID
Practice Address - State:NY
Practice Address - Zip Code:14521-9401
Practice Address - Country:US
Practice Address - Phone:607-403-0065
Practice Address - Fax:607-403-0093
Is Sole Proprietor?:No
Enumeration Date:2016-10-13
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04617121Medicaid
NY020239OtherLICENSE
NYJ400349805Medicare PIN