Provider Demographics
NPI:1346584034
Name:STUCKER, SUE A (NP)
Entity Type:Individual
Prefix:
First Name:SUE
Middle Name:A
Last Name:STUCKER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:182 INTREPID LN
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13205-2545
Mailing Address - Country:US
Mailing Address - Phone:315-218-7020
Mailing Address - Fax:
Practice Address - Street 1:182 INTREPID LN
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13205-2545
Practice Address - Country:US
Practice Address - Phone:315-218-7020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-19
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY534902-1163W00000X
NYF338786363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY534902-1OtherRN
NYF338786OtherNP