Provider Demographics
NPI:1497230742
Name:SHORT, ALYCIA (PA-C)
Entity Type:Individual
Prefix:
First Name:ALYCIA
Middle Name:
Last Name:SHORT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 LYON PL
Mailing Address - Street 2:
Mailing Address - City:OGDENSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13669-2590
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3 LYON PL
Practice Address - Street 2:
Practice Address - City:OGDENSBURG
Practice Address - State:NY
Practice Address - Zip Code:13669-2590
Practice Address - Country:US
Practice Address - Phone:315-713-6643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-02
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022701363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05448137Medicaid