Healthcare Provider Details

I. General information

NPI: 1609541051
Provider Name (Legal Business Name): THEPHWC LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2021
Last Update Date: 08/09/2021
Certification Date: 08/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1942 MILITARY TPKE
PLATTSBURGH NY
12901-7375
US

IV. Provider business mailing address

334 CORNELIA ST
PLATTSBURGH NY
12901-2329
US

V. Phone/Fax

Practice location:
  • Phone: 518-310-3644
  • Fax: 518-310-3645
Mailing address:
  • Phone: 518-578-4749
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KELSEY JUNTUNEN
Title or Position: OFFICE MANAGER
Credential:
Phone: 518-578-4749