Basic Information
| Provider Information | |||||||||
| NPI: | 1942804794 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | UTZ | ||||||||
| FirstName: | VICTORIA | ||||||||
| MiddleName: | ROSE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 67 NORTHRIDGE DR | ||||||||
| Address2: | |||||||||
| City: | WEST SENECA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142244408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7169975776 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 ATWELL RD | ||||||||
| Address2: | |||||||||
| City: | COOPERSTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 133261301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6075473456 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2020 | ||||||||
| LastUpdateDate: | 02/25/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 025514 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 025514 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 025514 | 01 | NY | NEW YORK STATE LICENSURE | OTHER |