Basic Information
| Provider Information | |||||||||
| NPI: | 1467564955 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MERRIMAN | ||||||||
| FirstName: | JOANN | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 711 TROY SCHENECTADY RD STE 203 | ||||||||
| Address2: | |||||||||
| City: | LATHAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121102461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187823700 | ||||||||
| FaxNumber: | 5187823799 | ||||||||
| Practice Location | |||||||||
| Address1: | 258 HOOSICK ST | ||||||||
| Address2: | STE 100 | ||||||||
| City: | TROY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121802444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5182720232 | ||||||||
| FaxNumber: | 5182724083 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 01/26/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 004214 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 01828697 | 05 | NY | MEDICAID | 140416000075 | 01 | NY | FIDELIS | OTHER | 140416000074 | 01 | NY | FIDELIS | OTHER |