Provider Demographics
NPI:1538109616
Name:HALL, BRIAN W (RPA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:W
Last Name:HALL
Suffix:
Gender:M
Credentials:RPA
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 725
Mailing Address - Street 2:
Mailing Address - City:COOPERSTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13326-0725
Mailing Address - Country:US
Mailing Address - Phone:518-673-5555
Mailing Address - Fax:518-673-5761
Practice Address - Street 1:56 MONTGOMERY ST
Practice Address - Street 2:
Practice Address - City:CANAJOHARIE
Practice Address - State:NY
Practice Address - Zip Code:13317-1212
Practice Address - Country:US
Practice Address - Phone:518-673-5555
Practice Address - Fax:518-673-5761
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002006363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01270337Medicaid
NYS12970Medicare UPIN
NY01270337Medicaid