Basic Information
| Provider Information | |||||||||
| NPI: | 1689672230 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIRK | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 792 N MAIN ST | ||||||||
| Address2: | STE 100B | ||||||||
| City: | NORTH SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132121661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154711044 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 E GENESEE ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132101892 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154711044 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2005 | ||||||||
| LastUpdateDate: | 09/11/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 009022 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 1689672230 | 01 | NY | NPI | OTHER |