Provider Demographics
NPI:1033778378
Name:BRECKENRIDGE, KRISTINA MARIE (PA)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:MARIE
Last Name:BRECKENRIDGE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:1001 W FAYETTE ST STE 400
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13204-2866
Mailing Address - Country:US
Mailing Address - Phone:315-937-3433
Mailing Address - Fax:315-634-4677
Practice Address - Street 1:739 IRVING AVE STE 450
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1663
Practice Address - Country:US
Practice Address - Phone:315-470-7364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-11
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY024149363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY024149OtherLICENSE