Basic Information
| Provider Information | |||||||||
| NPI: | 1699775254 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUTMAN | ||||||||
| FirstName: | ALAN | ||||||||
| MiddleName: | JAY | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 91 CHENANGO BRIDGE RD | ||||||||
| Address2: | |||||||||
| City: | BINGHAMTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 139011293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6076484151 | ||||||||
| FaxNumber: | 6076487138 | ||||||||
| Practice Location | |||||||||
| Address1: | 91 CHENANGO BRIDGE RD | ||||||||
| Address2: | |||||||||
| City: | BINGHAMTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 139011293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6076484151 | ||||||||
| FaxNumber: | 6076487138 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2005 | ||||||||
| LastUpdateDate: | 10/05/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 001400 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 028443772 | 05 | NY | MEDICAID |