Provider Demographics
NPI:1780082313
Name:KOSHY, MERLYN JACOB (PA)
Entity type:Individual
Prefix:MRS
First Name:MERLYN
Middle Name:JACOB
Last Name:KOSHY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MRS
Other - First Name:MERLYN
Other - Middle Name:
Other - Last Name:JACOB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:571 SAINT JOSEPHS BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-3230
Mailing Address - Country:US
Mailing Address - Phone:607-271-2050
Mailing Address - Fax:607-873-1244
Practice Address - Street 1:600 ROE AVENUE
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14905-1629
Practice Address - Country:US
Practice Address - Phone:607-737-4508
Practice Address - Fax:607-735-5738
Is Sole Proprietor?:No
Enumeration Date:2014-12-13
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00351600363A00000X
NY018251363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103367085Medicaid
NY04342201Medicaid