MEDICARE: COREY HOUGHTLING

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	031072	NY

General Provider Information

NPI Number	:	1093587149
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COREY HOUGHTLING

Provider Business Mailing Address
First Line	:	5688 W WAUTOMA BEACH RD
Second Line	:
City	:	HILTON
State	:	NY
Zip	:	14468-9126
Country	:	US
Telephone Number	:	585-944-6317
Fax Number	:

Provider Business Practice Location Address
First Line	:	5688 W WAUTOMA BEACH RD
Second Line	:
City	:	HILTON
State	:	NY
Zip	:	14468-9126
Country	:	US
Telephone Number	:	585-944-6317
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/23/2023
Last Update Date	:	03/08/2024

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Directions to “ COREY HOUGHTLING ” Practice Location

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