Provider Demographics
NPI:1912950445
Name:KRAEGER, EILEEN R (PA)
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:R
Last Name:KRAEGER
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 1:53 PUBLIC SQ
Mailing Address - Street 2:SUITE 202
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-2674
Mailing Address - Country:US
Mailing Address - Phone:315-786-8408
Mailing Address - Fax:315-786-6368
Practice Address - Street 1:53 PUBLIC SQ
Practice Address - Street 2:SUITE 202
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-2674
Practice Address - Country:US
Practice Address - Phone:315-786-8408
Practice Address - Fax:315-786-6368
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009635363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPA0740Medicare ID - Type Unspecified
NYQ38910Medicare UPIN