Provider Demographics
NPI:1831829001
Name:SUN, IRENE (PA)
Entity type:Individual
Prefix:MISS
First Name:IRENE
Middle Name:
Last Name:SUN
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:ELM AND CARLTON STREET
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14263
Mailing Address - Country:US
Mailing Address - Phone:716-845-2300
Mailing Address - Fax:
Practice Address - Street 1:ELM AND CARLTON STREET
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14263
Practice Address - Country:US
Practice Address - Phone:716-845-2300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-12
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NY363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant