Provider Demographics
NPI:1083789515
Name:KIAH, TRUDY M (RPAC)
Entity Type:Individual
Prefix:
First Name:TRUDY
Middle Name:M
Last Name:KIAH
Suffix:
Gender:F
Credentials:RPAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 STATE ST
Mailing Address - Street 2:
Mailing Address - City:OGDENSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13669-3347
Mailing Address - Country:US
Mailing Address - Phone:315-393-9269
Mailing Address - Fax:315-393-3541
Practice Address - Street 1:921 STATE ST
Practice Address - Street 2:
Practice Address - City:OGDENSBURG
Practice Address - State:NY
Practice Address - Zip Code:13669-3347
Practice Address - Country:US
Practice Address - Phone:315-393-9269
Practice Address - Fax:315-393-3541
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0071951363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01330116Medicaid
NY01330116Medicaid