Provider Demographics
NPI:1053484535
Name:TRENT, KIMBERLY S (PA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:S
Last Name:TRENT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:A
Other - Last Name:SANTAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:104 UNION AVE
Mailing Address - Street 2:SUITE 804
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203-1843
Mailing Address - Country:US
Mailing Address - Phone:315-703-5049
Mailing Address - Fax:315-703-5079
Practice Address - Street 1:301 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-1807
Practice Address - Country:US
Practice Address - Phone:315-448-5111
Practice Address - Fax:315-703-5079
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008402363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P70322Medicare UPIN
NYDD2800Medicare ID - Type Unspecified