Provider Demographics
NPI:1215970629
Name:AMODIO, KIMBERLY M (PA)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:M
Last Name:AMODIO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:M
Other - Last Name:HERZOG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1000 E GENESEE ST
Mailing Address - Street 2:SUITE 205 & 206
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1892
Mailing Address - Country:US
Mailing Address - Phone:315-464-1600
Mailing Address - Fax:315-464-1601
Practice Address - Street 1:1000 E GENESEE ST
Practice Address - Street 2:SUITE 205 & 206
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1892
Practice Address - Country:US
Practice Address - Phone:315-464-1600
Practice Address - Fax:315-464-1601
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007560363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02412206Medicaid
NY02412206Medicaid