Provider Demographics
NPI:1891750519
Name:TUTTLE, BRIE D (PAC)
Entity Type:Individual
Prefix:MISS
First Name:BRIE
Middle Name:D
Last Name:TUTTLE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1729 BURRSTONE RD
Mailing Address - Street 2:
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413-1001
Mailing Address - Country:US
Mailing Address - Phone:318-798-1840
Mailing Address - Fax:315-798-1648
Practice Address - Street 1:1729 BURRSTONE RD
Practice Address - Street 2:
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413
Practice Address - Country:US
Practice Address - Phone:318-798-1840
Practice Address - Fax:315-798-1648
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2018-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013110363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01335432Medicaid