Basic Information
| Provider Information | |||||||||
| NPI: | 1598797102 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MENARD | ||||||||
| FirstName: | ALFRED | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 707 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109402650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453337575 | ||||||||
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| Practice Location | |||||||||
| Address1: | 707 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109402650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453337575 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 11/08/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 005443 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | 005443 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 02642919 | 05 | NY | MEDICAID |