Provider Demographics
NPI:1063442481
Name:CLOONAN, DEBORAH L (PA)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:L
Last Name:CLOONAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:DEBORAH
Other - Middle Name:L
Other - Last Name:NICHOLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:140 W 6TH ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-2525
Mailing Address - Country:US
Mailing Address - Phone:315-342-6215
Mailing Address - Fax:315-342-6219
Practice Address - Street 1:140 W 6TH ST
Practice Address - Street 2:SUITE 110
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-2525
Practice Address - Country:US
Practice Address - Phone:315-342-6215
Practice Address - Fax:315-342-6219
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010341363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02631932Medicaid
NYJ400040841Medicare PIN