Provider Demographics
NPI:1396724894
Name:DETORE, JOANNE (PA)
Entity type:Individual
Prefix:
First Name:JOANNE
Middle Name:
Last Name:DETORE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 304
Mailing Address - Street 2:
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-0304
Mailing Address - Country:US
Mailing Address - Phone:518-926-1770
Mailing Address - Fax:518-926-1799
Practice Address - Street 1:2 BROAD STREET PLZ
Practice Address - Street 2:BROAD STREET MEDICAL GROUP
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-4363
Practice Address - Country:US
Practice Address - Phone:518-926-1770
Practice Address - Fax:518-926-1799
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2012-06-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY006825363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP00055451OtherRR MEDICARE
NY02340921Medicaid
NYP00055451OtherRR MEDICARE
NY02340921Medicaid