Provider Demographics
NPI:1558560995
Name:TUTTLE, KIMBERLY JO (PA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JO
Last Name:TUTTLE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:JO
Other - Last Name:WILLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:495 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CANANDAIGUA
Mailing Address - State:NY
Mailing Address - Zip Code:14424-1283
Mailing Address - Country:US
Mailing Address - Phone:585-393-3515
Mailing Address - Fax:
Practice Address - Street 1:495 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424-1283
Practice Address - Country:US
Practice Address - Phone:585-393-3515
Practice Address - Fax:585-393-3515
Is Sole Proprietor?:No
Enumeration Date:2007-07-16
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03385908Medicaid
NY03385908Medicaid