Healthcare Provider Details

I. General information

NPI: 1235394388
Provider Name (Legal Business Name): SUSAN K STUCK PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2008
Last Update Date: 08/08/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 EAST ADAMS STREET
SYRACUSE NY
13210
US

IV. Provider business mailing address

251 SALINA MEADOWS PARKWAY SUITE 100
SYRACUSE NY
13212
US

V. Phone/Fax

Practice location:
  • Phone: 315-464-8035
  • Fax: 315-464-5108
Mailing address:
  • Phone: 315-464-2000
  • Fax: 315-464-2010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number012641
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number6027
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number23012641
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number012641
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: