Provider Demographics
NPI:1942337266
Name:OLIPHANT, JOHN B (RPAC, ATC)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:B
Last Name:OLIPHANT
Suffix:
Gender:M
Credentials:RPAC, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:972 KENSINGTON CT
Mailing Address - Street 2:
Mailing Address - City:VICTOR
Mailing Address - State:NY
Mailing Address - Zip Code:14564-9367
Mailing Address - Country:US
Mailing Address - Phone:585-742-3452
Mailing Address - Fax:
Practice Address - Street 1:1160 CORPORATE DR
Practice Address - Street 2:HEALTHWORKS
Practice Address - City:FARMINGTON
Practice Address - State:NY
Practice Address - Zip Code:14425-9534
Practice Address - Country:US
Practice Address - Phone:585-924-1550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5647363A00000X
NY005647363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant