Provider Demographics
NPI:1033143391
Name:MEKOSH, SUSAN L (PA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:MEKOSH
Suffix:
Gender:F
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 2000
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:NY
Mailing Address - Zip Code:12534-2000
Mailing Address - Country:US
Mailing Address - Phone:518-828-8363
Mailing Address - Fax:518-697-3388
Practice Address - Street 1:1301 RIVER ST
Practice Address - Street 2:SUITE 204
Practice Address - City:VALATIE
Practice Address - State:NY
Practice Address - Zip Code:12184-9694
Practice Address - Country:US
Practice Address - Phone:518-758-1766
Practice Address - Fax:518-758-1439
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007248363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q08191Medicare UPIN
NY5150L1Medicare PIN