Provider Demographics
NPI:1720128911
Name:HUTMAN, MINDY (PA)
Entity Type:Individual
Prefix:
First Name:MINDY
Middle Name:
Last Name:HUTMAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 S 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:08904-2515
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 PELHAM PKWY S
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-1138
Practice Address - Country:US
Practice Address - Phone:718-918-3060
Practice Address - Fax:718-918-4469
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009558363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant