Provider Demographics
NPI:1376534156
Name:LANG-DISTEFANO, SHERYL (PA)
Entity Type:Individual
Prefix:
First Name:SHERYL
Middle Name:
Last Name:LANG-DISTEFANO
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 1:792 N MAIN ST
Mailing Address - Street 2:SUITE 100A
Mailing Address - City:NORTH SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13212-1644
Mailing Address - Country:US
Mailing Address - Phone:315-423-9722
Mailing Address - Fax:315-423-9687
Practice Address - Street 1:792 1/2 N MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTH SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13212-1670
Practice Address - Country:US
Practice Address - Phone:315-701-0500
Practice Address - Fax:315-701-3650
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0017931363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYH43671Medicare UPIN
NYBB9694Medicare ID - Type Unspecified