Provider Demographics
NPI:1427096601
Name:BRUNDAGE, SUZANNE MARIE (PA)
Entity type:Individual
Prefix:MS
First Name:SUZANNE
Middle Name:MARIE
Last Name:BRUNDAGE
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:PO BOX 985
Mailing Address - Street 2:
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-0985
Mailing Address - Country:US
Mailing Address - Phone:518-793-1000
Mailing Address - Fax:518-793-3125
Practice Address - Street 1:11 MURRAY ST
Practice Address - Street 2:
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-4311
Practice Address - Country:US
Practice Address - Phone:518-793-1000
Practice Address - Fax:518-793-3125
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009112363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02802275Medicaid
NYPA1510Medicare ID - Type Unspecified
NY02802275Medicaid