Provider Demographics
NPI:1588734024
Name:HODGEMAN, PAUL (RPAC)
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:
Last Name:HODGEMAN
Suffix:
Gender:M
Credentials:RPAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:346 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2580
Mailing Address - Country:US
Mailing Address - Phone:607-763-8101
Mailing Address - Fax:607-763-8049
Practice Address - Street 1:30 HARRISON ST
Practice Address - Street 2:SUITE 460
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2161
Practice Address - Country:US
Practice Address - Phone:607-763-8101
Practice Address - Fax:607-763-8049
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006485363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01965613Medicaid
NY01965613Medicaid
NYBB4029Medicare ID - Type Unspecified