Basic Information
| Provider Information | |||||||||
| NPI: | 1215419775 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FEDORICH | ||||||||
| FirstName: | BRIANNA | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8810 DAYLIGHT DR | ||||||||
| Address2: | |||||||||
| City: | LIVERPOOL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130901594 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8566258299 | ||||||||
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| Practice Location | |||||||||
| Address1: | 736 IRVING AVE | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132101690 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154707111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2018 | ||||||||
| LastUpdateDate: | 08/31/2018 | ||||||||
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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 | 363AS0400X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.