Healthcare Provider Details

I. General information

NPI: 1063535094
Provider Name (Legal Business Name): QIANA LENETTE SUTTON PA PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 07/25/2025
Certification Date: 07/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4900 BROAD RD
SYRACUSE NY
13215-2265
US

IV. Provider business mailing address

4900 BROAD RD
SYRACUSE NY
13215-2265
US

V. Phone/Fax

Practice location:
  • Phone: 315-492-3446
  • Fax: 315-492-5999
Mailing address:
  • Phone: 315-492-3446
  • Fax: 315-492-5999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number015242
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number25MP00043700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: