=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518792704
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENNETH ORDIZ MUTIA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/06/2024
-----------------------------------------------------
Last Update Date | 12/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11050 MT BELVEDERE BLVD
-----------------------------------------------------
City | FORT DRUM
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13602-2603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-772-8813
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8640 PECK ST
-----------------------------------------------------
City | EVANS MILLS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13637-7709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-522-6001
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------