Provider Demographics
NPI:1841298510
Name:PATTISON, THETA S (MD)
Entity type:Individual
Prefix:
First Name:THETA
Middle Name:S
Last Name:PATTISON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2508 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:ALTAMONT
Mailing Address - State:NY
Mailing Address - Zip Code:12009-9485
Mailing Address - Country:US
Mailing Address - Phone:518-690-0177
Mailing Address - Fax:518-690-0169
Practice Address - Street 1:2508 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:ALTAMONT
Practice Address - State:NY
Practice Address - Zip Code:12009-9485
Practice Address - Country:US
Practice Address - Phone:518-690-0177
Practice Address - Fax:518-690-0169
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY188200207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01429336Medicaid
F64545Medicare UPIN
NY01429336Medicaid