Provider Demographics
NPI:1487305231
Name:POPKIN, THIA LEE
Entity type:Individual
Prefix:
First Name:THIA
Middle Name:LEE
Last Name:POPKIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2779 BAILEY CREEK RD
Mailing Address - Street 2:
Mailing Address - City:CORNING
Mailing Address - State:NY
Mailing Address - Zip Code:14830-8907
Mailing Address - Country:US
Mailing Address - Phone:607-368-1658
Mailing Address - Fax:
Practice Address - Street 1:500 5TH AVE
Practice Address - Street 2:
Practice Address - City:OWEGO
Practice Address - State:NY
Practice Address - Zip Code:13827-1620
Practice Address - Country:US
Practice Address - Phone:607-687-1122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-13
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF310590363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health