Provider Demographics
NPI:1578072096
Name:MAITLAND, MORGAN A (PA)
Entity Type:Individual
Prefix:
First Name:MORGAN
Middle Name:A
Last Name:MAITLAND
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MORGAN
Other - Middle Name:
Other - Last Name:GUALTIERI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2209 GENESEE STREET
Mailing Address - Street 2:BUSINESS OFFICE -ROOM 310
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501
Mailing Address - Country:US
Mailing Address - Phone:315-801-3282
Mailing Address - Fax:315-801-8391
Practice Address - Street 1:1256 CULVER AVE
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-4253
Practice Address - Country:US
Practice Address - Phone:315-738-7186
Practice Address - Fax:315-738-0188
Is Sole Proprietor?:No
Enumeration Date:2017-09-27
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021383363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04925260Medicaid