Provider Demographics
NPI:1215673710
Name:ODDO, KIARA LYNN (PA-C)
Entity type:Individual
Prefix:
First Name:KIARA
Middle Name:LYNN
Last Name:ODDO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KIARA
Other - Middle Name:LYNN
Other - Last Name:BLANDEBURGO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:100 NICOLLS ROAD HSC T12 RM 080
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794
Mailing Address - Country:US
Mailing Address - Phone:631-774-1398
Mailing Address - Fax:
Practice Address - Street 1:100 NICOLLS ROAD HSC T12 RM 080
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794
Practice Address - Country:US
Practice Address - Phone:631-444-1116
Practice Address - Fax:631-444-1535
Is Sole Proprietor?:No
Enumeration Date:2022-05-08
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant