Healthcare Provider Details

I. General information

NPI: 1902900111
Provider Name (Legal Business Name): HUDSON HEADWATERS HEALTH NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2006
Last Update Date: 02/23/2024
Certification Date: 02/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 TOM PHELPS LANE
MINEVILLE NY
12956-0480
US

IV. Provider business mailing address

9 CAREY RD
QUEENSBURY NY
12804-7880
US

V. Phone/Fax

Practice location:
  • Phone: 518-942-7123
  • Fax: 518-942-7041
Mailing address:
  • Phone: 518-761-0300
  • Fax: 518-824-2388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number StateNY
# 6
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNY
# 7
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LAURA PASCO
Title or Position: EXECUTIVE VP, CFO
Credential:
Phone: 518-761-0300