Provider Demographics
NPI:1740681238
Name:DAVID, MARJORIE GRACE (PA-C)
Entity type:Individual
Prefix:
First Name:MARJORIE
Middle Name:GRACE
Last Name:DAVID
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARJORIE
Other - Middle Name:
Other - Last Name:FISHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2209 GENESEE ST-BUSINESS OFFICE ROOM 310
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-5930
Mailing Address - Country:US
Mailing Address - Phone:315-801-3282
Mailing Address - Fax:315-801-8391
Practice Address - Street 1:8411 SENECA TPKE
Practice Address - Street 2:
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413-4912
Practice Address - Country:US
Practice Address - Phone:315-624-8500
Practice Address - Fax:315-624-8515
Is Sole Proprietor?:No
Enumeration Date:2014-09-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04323635Medicaid
NY170726000208OtherFIDELIS