Provider Demographics
NPI:1205867736
Name:SLAVICH, SALLY S (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MR
First Name:SALLY
Middle Name:S
Last Name:SLAVICH
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4140 WEST SHORE MANOR
Mailing Address - Street 2:
Mailing Address - City:JAMESVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13078
Mailing Address - Country:US
Mailing Address - Phone:315-469-3601
Mailing Address - Fax:
Practice Address - Street 1:800 IRVING AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2716
Practice Address - Country:US
Practice Address - Phone:315-425-2433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007866-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYVAD000Medicare UPIN