Provider Demographics
NPI:1932106218
Name:KINSELLA, BRIGET T (PA)
Entity Type:Individual
Prefix:
First Name:BRIGET
Middle Name:T
Last Name:KINSELLA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 W FAYETTE ST
Mailing Address - Street 2:STE 400
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13204-2859
Mailing Address - Country:US
Mailing Address - Phone:315-472-1488
Mailing Address - Fax:315-472-8060
Practice Address - Street 1:736 IRVING AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1687
Practice Address - Country:US
Practice Address - Phone:315-470-7111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2009-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009260363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP00198567Medicare PIN
P69826Medicare UPIN