Provider Demographics
NPI:1588643472
Name:FEDORWICH, CHRISTY L (PA)
Entity Type:Individual
Prefix:MS
First Name:CHRISTY
Middle Name:L
Last Name:FEDORWICH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 LEWIS RD
Mailing Address - Street 2:2ND FL
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905
Mailing Address - Country:US
Mailing Address - Phone:607-770-0025
Mailing Address - Fax:607-729-3986
Practice Address - Street 1:30 HARRISON ST STE 250
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2176
Practice Address - Country:US
Practice Address - Phone:607-763-6580
Practice Address - Fax:607-763-6782
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001613363A00000X
NJMP00218800363A00000X
NY024817363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001613OtherPHYSICIAN LICENSE
CT004236007Medicaid
CT1064074OtherNCCPA LICENSE
NJ25MP00218800OtherSTATE
NJ25MP00218800OtherSTATE