Provider Demographics
NPI:1427809292
Name:KO, BRENDA (PT, RN)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:KO
Suffix:
Gender:F
Credentials:PT, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5008 WOODSIDE RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-1748
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:973 JAMES STREET
Practice Address - Street 2:3RD FLOOR, MIST OFFICE
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203
Practice Address - Country:US
Practice Address - Phone:315-458-7373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-29
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY533953163WC0400X
NY013279225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No163WC0400XNursing Service ProvidersRegistered NurseCase Management