Provider Demographics
NPI:1558048454
Name:MUNDT, NOAH DAVID
Entity Type:Individual
Prefix:
First Name:NOAH
Middle Name:DAVID
Last Name:MUNDT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 SILKWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:SPENCERPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14559-2403
Mailing Address - Country:US
Mailing Address - Phone:585-507-3273
Mailing Address - Fax:
Practice Address - Street 1:20 SILKWOOD CIR
Practice Address - Street 2:
Practice Address - City:SPENCERPORT
Practice Address - State:NY
Practice Address - Zip Code:14559-2403
Practice Address - Country:US
Practice Address - Phone:585-507-3273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-03
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030253363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant