Provider Demographics
NPI:1558316059
Name:TREADWELL, NANETTE LAMM (RPAC)
Entity type:Individual
Prefix:
First Name:NANETTE
Middle Name:LAMM
Last Name:TREADWELL
Suffix:
Gender:F
Credentials:RPAC
Other - Prefix:
Other - First Name:NANETTE
Other - Middle Name:DOROTHY
Other - Last Name:TREADWELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPAC
Mailing Address - Street 1:PO BOX 41
Mailing Address - Street 2:
Mailing Address - City:SOUTH KORTRIGHT
Mailing Address - State:NY
Mailing Address - Zip Code:13842-0041
Mailing Address - Country:US
Mailing Address - Phone:607-538-1307
Mailing Address - Fax:845-586-3411
Practice Address - Street 1:7571 NY-54
Practice Address - Street 2:
Practice Address - City:BATH
Practice Address - State:NY
Practice Address - Zip Code:14810
Practice Address - Country:US
Practice Address - Phone:607-776-8522
Practice Address - Fax:845-586-3411
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004508363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02458991Medicaid
NYDD6688Medicare ID - Type UnspecifiedUPSTATE
NY02458991Medicaid