Basic Information
| Provider Information | |||||||||
| NPI: | 1083789515 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIAH | ||||||||
| FirstName: | TRUDY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | RPAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 921 STATE ST | ||||||||
| Address2: | |||||||||
| City: | OGDENSBURG | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136693347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153939269 | ||||||||
| FaxNumber: | 3153933541 | ||||||||
| Practice Location | |||||||||
| Address1: | 921 STATE ST | ||||||||
| Address2: | |||||||||
| City: | OGDENSBURG | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136693347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153939269 | ||||||||
| FaxNumber: | 3153933541 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2006 | ||||||||
| LastUpdateDate: | 10/06/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0071951 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 01330116 | 05 | NY | MEDICAID |