Provider Demographics
NPI:1205146941
Name:PERRY, MICHAEL JOSEPH (PMHNP)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:PERRY
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:995 BEAVER CREEK RD
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13480-2403
Mailing Address - Country:US
Mailing Address - Phone:315-737-1542
Mailing Address - Fax:
Practice Address - Street 1:1400 NOYES ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-3854
Practice Address - Country:US
Practice Address - Phone:315-738-4075
Practice Address - Fax:907-260-3697
Is Sole Proprietor?:No
Enumeration Date:2010-10-15
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1478363LP0808X
NYF401302-1363LP0808X
NY401302363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1619189Medicaid