Provider Demographics
NPI:1326020033
Name:EDERER, MICHELLE MARGARET (BA,MA, PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:MARGARET
Last Name:EDERER
Suffix:
Gender:F
Credentials:BA,MA, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 JORDAN ST
Mailing Address - Street 2:
Mailing Address - City:SKANEATELES
Mailing Address - State:NY
Mailing Address - Zip Code:13152-1113
Mailing Address - Country:US
Mailing Address - Phone:315-391-1281
Mailing Address - Fax:
Practice Address - Street 1:3504 W GENESEE ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13219-2008
Practice Address - Country:US
Practice Address - Phone:315-350-3305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006151363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02208226Medicaid
NY02208226Medicaid