Provider Demographics
NPI:1215209028
Name:SIECHEN, STEPHANIE M (PA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:M
Last Name:SIECHEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1729 BURRSTONE RD
Mailing Address - Street 2:
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413-1001
Mailing Address - Country:US
Mailing Address - Phone:315-798-1567
Mailing Address - Fax:315-798-1575
Practice Address - Street 1:1729 BURRSTONE RD
Practice Address - Street 2:
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413-1001
Practice Address - Country:US
Practice Address - Phone:315-798-1567
Practice Address - Fax:315-798-1575
Is Sole Proprietor?:No
Enumeration Date:2012-02-09
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015439363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03436495Medicaid