Provider Demographics
NPI:1063535094
Name:SUTTON, QIANA LENETTE (PA- C)
Entity type:Individual
Prefix:
First Name:QIANA
Middle Name:LENETTE
Last Name:SUTTON
Suffix:
Gender:F
Credentials:PA- C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4900 BROAD RD
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13215-2265
Mailing Address - Country:US
Mailing Address - Phone:315-492-3446
Mailing Address - Fax:315-492-5999
Practice Address - Street 1:4900 BROAD RD
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13215-2265
Practice Address - Country:US
Practice Address - Phone:315-492-3446
Practice Address - Fax:315-492-5999
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00043700363AS0400X
NY015242363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03788929Medicaid
NY03788929Medicaid