Provider Demographics
NPI:1558479204
Name:KRZYZAK, SUSAN A (NP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:A
Last Name:KRZYZAK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:239 ONEIDA ST
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:NY
Mailing Address - Zip Code:13069-1228
Mailing Address - Country:US
Mailing Address - Phone:315-598-4715
Mailing Address - Fax:315-598-4733
Practice Address - Street 1:522 S 4TH ST
Practice Address - Street 2:SUITE 500
Practice Address - City:FULTON
Practice Address - State:NY
Practice Address - Zip Code:13069-2946
Practice Address - Country:US
Practice Address - Phone:315-598-4740
Practice Address - Fax:315-598-4719
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF331665363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBB7631Medicare ID - Type Unspecified
NYS93575Medicare UPIN