Provider Demographics
NPI:1255378980
Name:MOYER-MATTESON, GINNY MARIE (RPA-C)
Entity type:Individual
Prefix:MS
First Name:GINNY
Middle Name:MARIE
Last Name:MOYER-MATTESON
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:GINNY
Other - Middle Name:
Other - Last Name:GREENE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPA-C
Mailing Address - Street 1:15 S MAIN ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14701-6626
Mailing Address - Country:US
Mailing Address - Phone:716-483-2320
Mailing Address - Fax:716-484-2582
Practice Address - Street 1:15 S MAIN ST
Practice Address - Street 2:SUITE 110
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-6626
Practice Address - Country:US
Practice Address - Phone:716-483-2320
Practice Address - Fax:716-484-2582
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009358363A00000X
NY009358-1363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0581Medicare PIN
PA0586Medicare PIN
PA0588Medicare PIN
PA0583Medicare PIN
NYQ31836Medicare UPIN
PA0582Medicare PIN
PA0585Medicare PIN
PA0580Medicare PIN
PA0584Medicare PIN