Provider Demographics
NPI:1164784542
Name:SENENKO, STEPHEN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:
Last Name:SENENKO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:739 IRVING AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1668
Mailing Address - Country:US
Mailing Address - Phone:315-479-5070
Mailing Address - Fax:315-701-2525
Practice Address - Street 1:739 IRVING AVE STE 200
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210
Practice Address - Country:US
Practice Address - Phone:315-479-5070
Practice Address - Fax:315-701-2525
Is Sole Proprietor?:No
Enumeration Date:2012-06-12
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
020247363A00000X
NY020247363AM0700X
NY007505-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY007505-1OtherUNIVERSITY OF THE STATE OF NEW YORK EDUCATION DEPARTMENT OFFICE OF THE PROFESSIO
NY020247OtherSTATE OF NEW YORK EDUCATION DEPARTMENT OFFICE OF THE PROFESSIONS