Basic Information
| Provider Information | |||||||||
| NPI: | 1467567644 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCKINNEY | ||||||||
| FirstName: | SUE | ||||||||
| MiddleName: | PETERSEN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BROWER | ||||||||
| OtherFirstName: | DONNA | ||||||||
| OtherMiddleName: | SUE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 711 TROY SCHENECTADY RD STE 203 | ||||||||
| Address2: | |||||||||
| City: | LATHAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121102461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187823700 | ||||||||
| FaxNumber: | 5187823799 | ||||||||
| Practice Location | |||||||||
| Address1: | 3732 CARMAN RD | ||||||||
| Address2: | |||||||||
| City: | SCHENECTADY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 123035422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5183564132 | ||||||||
| FaxNumber: | 5183553996 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 01/26/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 002820 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 000412001001 | 01 | NY | BSNENY | OTHER | 070507000061 | 01 | NY | FIDELIS | OTHER | 710843 | 01 | NY | MVP | OTHER | 02820226 | 05 | NY | MEDICAID |