Healthcare Provider Details

I. General information

NPI: 1336697929
Provider Name (Legal Business Name): KAYLEE C KING PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2016
Last Update Date: 12/27/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 EAST ADAMS STREET
SYRACUSE NY
13210-2306
US

IV. Provider business mailing address

251 SALINA MEADOWS PARKWAY SUITE 100
SYRACUSE NY
13212
US

V. Phone/Fax

Practice location:
  • Phone: 315-464-1800
  • Fax: 315-464-6238
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 Number030836
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA.0005886
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: