Provider Demographics
NPI:1720062896
Name:BROWN, REBECCA GRANDY (PA)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:GRANDY
Last Name:BROWN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:SUZANNE
Other - Last Name:GRANDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:301 PROSPECT AVE
Mailing Address - Street 2:CLINICAL AFFILIATES
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203-1807
Mailing Address - Country:US
Mailing Address - Phone:315-448-2876
Mailing Address - Fax:315-448-6325
Practice Address - Street 1:301 PROSPECT AVE
Practice Address - Street 2:CLINICAL AFFILIATES
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-1807
Practice Address - Country:US
Practice Address - Phone:315-448-2876
Practice Address - Fax:315-448-6325
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008131-1363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP41956Medicare UPIN
NYJ400052157Medicare PIN