Basic Information
| Provider Information | |||||||||
| NPI: | 1902213168 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIRACUSE | ||||||||
| FirstName: | KRISTEN | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SCHOBER | ||||||||
| OtherFirstName: | KRISTEN | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 18 BIRCHWOOD DR | ||||||||
| Address2: | |||||||||
| City: | FREDONIA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140631204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166724600 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 319 CENTRAL AVE | ||||||||
| Address2: | LEVEL B | ||||||||
| City: | DUNKIRK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140482137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7163636050 | ||||||||
| FaxNumber: | 7163636851 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2014 | ||||||||
| LastUpdateDate: | 05/05/2015 | ||||||||
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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 | 364SF0001X | F3385411 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Family Health | 363LF0000X | F338541-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 04007530 | 05 | NY | MEDICAID |