Provider Demographics
NPI:1386647444
Name:REDDY, MICHAEL (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:REDDY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2004
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-4504
Mailing Address - Country:US
Mailing Address - Phone:315-362-5285
Mailing Address - Fax:315-445-2936
Practice Address - Street 1:2 ELLINWOOD DR
Practice Address - Street 2:
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413-1102
Practice Address - Country:US
Practice Address - Phone:315-724-1012
Practice Address - Fax:157-245-2193
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY006120363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01798847Medicaid