Healthcare Provider Details

I. General information

NPI: 1184389975
Provider Name (Legal Business Name): SYDNEY LORRAINE PEACOCK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SYDNEY LORRAINE KRAEGER

II. Dates (important events)

Enumeration Date: 11/05/2021
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2685 E HENRIETTA RD
HENRIETTA NY
14467-9370
US

IV. Provider business mailing address

100 KINGS HWY S
ROCHESTER NY
14617-5504
US

V. Phone/Fax

Practice location:
  • Phone: 585-444-0058
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number027684
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: