Provider Demographics
NPI:1194067090
Name:REDDY, SAILASRI C (PA)
Entity type:Individual
Prefix:
First Name:SAILASRI
Middle Name:C
Last Name:REDDY
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 1:1729 BURRSTONE RD
Mailing Address - Street 2:ROOM #4102
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413-1001
Mailing Address - Country:US
Mailing Address - Phone:315-798-1702
Mailing Address - Fax:315-798-1726
Practice Address - Street 1:90 PRESIDENTIAL PLZ
Practice Address - Street 2:ROOM #4102
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-2240
Practice Address - Country:US
Practice Address - Phone:315-464-3938
Practice Address - Fax:315-464-5359
Is Sole Proprietor?:No
Enumeration Date:2013-03-19
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016336363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03609189Medicaid
NYJ400095406Medicare PIN