Provider Demographics
NPI:1659301729
Name:MIHM, TIMOTHY (PA)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:MIHM
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:357 GENESEE ST
Mailing Address - Street 2:SUITE # 2
Mailing Address - City:ONEIDA
Mailing Address - State:NY
Mailing Address - Zip Code:13421-2658
Mailing Address - Country:US
Mailing Address - Phone:315-363-2123
Mailing Address - Fax:315-363-2549
Practice Address - Street 1:357 GENESEE ST
Practice Address - Street 2:SUITE # 2
Practice Address - City:ONEIDA
Practice Address - State:NY
Practice Address - Zip Code:13421-2658
Practice Address - Country:US
Practice Address - Phone:315-363-2123
Practice Address - Fax:315-363-2549
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008726363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400353781OtherMEDICARE PTAN
NYP59995Medicare UPIN