Basic Information
| Provider Information | |||||||||
| NPI: | 1083648315 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PERDEK | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | MACKINNON | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 MCCLELLAN ST | ||||||||
| Address2: | 2 W - MSO | ||||||||
| City: | SCHENECTADY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 123041009 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1101 NOTT ST | ||||||||
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| City: | SCHENECTADY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 123082425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5182434000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 06/05/2014 | ||||||||
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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 | 363LA2200X | 302354 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LF0000X | 333880 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 000000092603 | 01 | NY | GHI-HMO | OTHER | 050806000037 | 01 | NY | FIDELIS CARE | OTHER | 788114 | 01 | NY | MVP | OTHER | 000490314003 | 01 | NY | BLUE SHIELD | OTHER | 7599225 | 01 | NY | GHI-PPO | OTHER |