Basic Information
| Provider Information | |||||||||
| NPI: | 1033778378 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRECKENRIDGE | ||||||||
| FirstName: | KRISTINA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 W FAYETTE ST STE 400 | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132042866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3159373433 | ||||||||
| FaxNumber: | 3156344677 | ||||||||
| Practice Location | |||||||||
| Address1: | 739 IRVING AVE STE 450 | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132101663 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154707364 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2019 | ||||||||
| LastUpdateDate: | 05/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 024149 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 024149 | 01 | NY | LICENSE | OTHER |