Basic Information
| Provider Information | |||||||||
| NPI: | 1710481643 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KRICKER | ||||||||
| FirstName: | SUSANNAH | ||||||||
| MiddleName: | LOUIS | ||||||||
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| Credential: | MD | ||||||||
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| 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: | 391 MYRTLE AVE STE 4A | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122083829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5182072273 | ||||||||
| FaxNumber: | 5182072293 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2018 | ||||||||
| LastUpdateDate: | 10/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 64038 | NY | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 313301 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.