Provider Demographics
NPI:1407452709
Name:JUDA, DYLAN L (PA)
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:L
Last Name:JUDA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6846 BUCKLEY RD STE 1
Mailing Address - Street 2:
Mailing Address - City:NORTH SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13212-4270
Mailing Address - Country:US
Mailing Address - Phone:315-410-6400
Mailing Address - Fax:
Practice Address - Street 1:6846 BUCKLEY RD STE 1
Practice Address - Street 2:
Practice Address - City:NORTH SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13212-4270
Practice Address - Country:US
Practice Address - Phone:315-410-6400
Practice Address - Fax:315-410-6410
Is Sole Proprietor?:No
Enumeration Date:2020-12-10
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026046363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant