Provider Demographics
NPI:1700228129
Name:AMSDELL, JACQUELINE BRITTANY (PA)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:BRITTANY
Last Name:AMSDELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:251 SALINA MEADOWS PKWY
Mailing Address - Street 2:STE 100
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13212-4576
Mailing Address - Country:US
Mailing Address - Phone:315-464-6255
Mailing Address - Fax:315-464-6251
Practice Address - Street 1:739 IRVING AVE
Practice Address - Street 2:SUITE 640
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210
Practice Address - Country:US
Practice Address - Phone:315-464-6255
Practice Address - Fax:315-464-6251
Is Sole Proprietor?:No
Enumeration Date:2013-07-26
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXPA08521363A00000X, 363AS0400X
NY025830363A00000X
CT4620363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX335901004Medicaid
TX335901001Medicaid
TX8745NYOtherBCBS
TX531771ZSWDMedicare PIN
TX8745NYOtherBCBS