Provider Demographics
NPI:1063879245
Name:SUJESKI, KERRI A (PA-C)
Entity type:Individual
Prefix:MS
First Name:KERRI
Middle Name:A
Last Name:SUJESKI
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 1:104 FOREST AVENUE
Mailing Address - Street 2:
Mailing Address - City:GLEN COVE
Mailing Address - State:NY
Mailing Address - Zip Code:11542
Mailing Address - Country:US
Mailing Address - Phone:516-759-5406
Mailing Address - Fax:516-759-5537
Practice Address - Street 1:104 FOREST AVENUE
Practice Address - Street 2:
Practice Address - City:GLEN COVE
Practice Address - State:NY
Practice Address - Zip Code:11542
Practice Address - Country:US
Practice Address - Phone:516-759-5406
Practice Address - Fax:516-759-5537
Is Sole Proprietor?:No
Enumeration Date:2016-01-19
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019243363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant