Provider Demographics
NPI:1154623882
Name:VANDUYNE, KAYLEIGH BREANNE (PA)
Entity type:Individual
Prefix:
First Name:KAYLEIGH
Middle Name:BREANNE
Last Name:VANDUYNE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 W FAYETTE ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13204-2856
Mailing Address - Country:US
Mailing Address - Phone:315-472-1488
Mailing Address - Fax:315-476-1792
Practice Address - Street 1:1991 BALSLEY RD
Practice Address - Street 2:
Practice Address - City:SENECA FALLS
Practice Address - State:NY
Practice Address - Zip Code:13148-6725
Practice Address - Country:US
Practice Address - Phone:315-539-9229
Practice Address - Fax:315-539-0940
Is Sole Proprietor?:No
Enumeration Date:2010-12-01
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014436363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03313848Medicaid
NY03313848Medicaid