Basic Information
| Provider Information | |||||||||
| NPI: | 1740533975 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MILBACK | ||||||||
| FirstName: | CHRISTINA | ||||||||
| MiddleName: | LYN | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6919 KASSONTA DR | ||||||||
| Address2: | |||||||||
| City: | JAMESVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130789600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154707411 | ||||||||
| FaxNumber: | 7162044501 | ||||||||
| Practice Location | |||||||||
| Address1: | 736 IRVING AVE | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132101687 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154707411 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2012 | ||||||||
| LastUpdateDate: | 02/02/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 016051 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.