Provider Demographics
NPI:1083654297
Name:MELTZ, THERESA A (PA)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:A
Last Name:MELTZ
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:PO BOX 2000
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:NY
Mailing Address - Zip Code:12534-2000
Mailing Address - Country:US
Mailing Address - Phone:518-828-8363
Mailing Address - Fax:518-697-3388
Practice Address - Street 1:71 PROSPECT AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:HUDSON
Practice Address - State:NY
Practice Address - Zip Code:12534-2907
Practice Address - Country:US
Practice Address - Phone:518-828-3327
Practice Address - Fax:518-697-8158
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003595-1363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS10120Medicare UPIN
NYW23281Medicare ID - Type UnspecifiedGROUP #
NY0F1951Medicare ID - Type Unspecified