Provider Demographics
NPI:1669599882
Name:RODNER, DYLAN (PA)
Entity type:Individual
Prefix:MR
First Name:DYLAN
Middle Name:
Last Name:RODNER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1001 W FAYETTE ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13204-2859
Mailing Address - Country:US
Mailing Address - Phone:315-449-3800
Mailing Address - Fax:315-449-1246
Practice Address - Street 1:5000 BRITTONFIELD PKWY
Practice Address - Street 2:SUITE A100
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-9226
Practice Address - Country:US
Practice Address - Phone:315-449-3800
Practice Address - Fax:315-449-1246
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT001653363AM0700X
NY008762363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY008762OtherSTATE LICENSE
NY008762OtherSTATE LICENSE
CTP92804Medicare UPIN