Healthcare Provider Details

I. General information

NPI: 1518792704
Provider Name (Legal Business Name): KENNETH ORDIZ MUTIA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2024
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11050 MT BELVEDERE BLVD
FORT DRUM NY
13602-2603
US

IV. Provider business mailing address

8640 PECK ST
EVANS MILLS NY
13637-7709
US

V. Phone/Fax

Practice location:
  • Phone: 315-772-8813
  • Fax:
Mailing address:
  • Phone: 914-522-6001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: