Basic Information
| Provider Information | |||||||||
| NPI: | 1912258856 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MU | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 571 SAINT JOSEPHS BLVD FL 2 | ||||||||
| Address2: | |||||||||
| City: | ELMIRA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 149013230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6072712050 | ||||||||
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| Practice Location | |||||||||
| Address1: | 45 MUD CREEK RD | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 169479529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702973746 | ||||||||
| FaxNumber: | 5702975127 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2012 | ||||||||
| LastUpdateDate: | 06/16/2016 | ||||||||
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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 | MA057079 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 018442 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 378943YHLY | 01 | PA | PA MEDICARE (NOVITAS) | OTHER | 04134483 | 05 | NY | MEDICAID |