Healthcare Provider Details

I. General information

NPI: 1407436710
Provider Name (Legal Business Name): BRIANNA BALDWIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2021
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 W GENESEE ST
CAMILLUS NY
13031-2238
US

IV. Provider business mailing address

301 PROSPECT AVE # MSO
SYRACUSE NY
13203-1807
US

V. Phone/Fax

Practice location:
  • Phone: 315-253-2333
  • Fax:
Mailing address:
  • Phone: 315-448-5111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number027535-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: