Provider Demographics
NPI:1023026549
Name:ENGLE, GARY N (PA)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:N
Last Name:ENGLE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2337
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13220-2337
Mailing Address - Country:US
Mailing Address - Phone:315-422-2933
Mailing Address - Fax:315-422-3909
Practice Address - Street 1:3926 STATE ROUTE 12
Practice Address - Street 2:
Practice Address - City:LYONS FALLS
Practice Address - State:NY
Practice Address - Zip Code:13368
Practice Address - Country:US
Practice Address - Phone:315-346-6824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000714363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01941560Medicaid
S28598Medicare UPIN
NY01941560Medicaid
NYPA2479Medicare PIN
NYP00603189Medicare PIN