Basic Information
| Provider Information | |||||||||
| NPI: | 1497909493 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PADANNAMACKAL | ||||||||
| FirstName: | SIJO | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1910 SOUTH RD | ||||||||
| Address2: | |||||||||
| City: | POUGHKEEPSIE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 126016027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8454540120 | ||||||||
| FaxNumber: | 8454546080 | ||||||||
| Practice Location | |||||||||
| Address1: | 1910 SOUTH RD | ||||||||
| Address2: | |||||||||
| City: | POUGHKEEPSIE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 126016027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8454540120 | ||||||||
| FaxNumber: | 8454546080 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2008 | ||||||||
| LastUpdateDate: | 09/30/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 012791 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 03114821 | 05 | NY | MEDICAID |