Provider Demographics
NPI:1497265797
Name:HAUCK, MARY KATHRYN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:KATHRYN
Last Name:HAUCK
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 1:904 HUDSON ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13219-1024
Mailing Address - Country:US
Mailing Address - Phone:315-345-1755
Mailing Address - Fax:
Practice Address - Street 1:739 IRVING AVE STE 200-300
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1651
Practice Address - Country:US
Practice Address - Phone:315-479-5070
Practice Address - Fax:315-701-2525
Is Sole Proprietor?:No
Enumeration Date:2017-10-02
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021462363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant