Provider Demographics
NPI:1215650346
Name:SCHULLER, KEVIN CHARLES (ACNPC-AG)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:CHARLES
Last Name:SCHULLER
Suffix:
Gender:M
Credentials:ACNPC-AG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 E GENESEE ST STE 205
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1853
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 E GENESEE ST STE 205
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1853
Practice Address - Country:US
Practice Address - Phone:315-464-1600
Practice Address - Fax:315-464-1601
Is Sole Proprietor?:No
Enumeration Date:2022-09-23
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY432494363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner