Healthcare Provider Details

I. General information

NPI: 1568295228
Provider Name (Legal Business Name): JORDAN MCKENZIE KILGALLEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KENZIE KILGALLEN

II. Dates (important events)

Enumeration Date: 08/20/2024
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 PROSPECT AVE
SYRACUSE NY
13203-1807
US

IV. Provider business mailing address

301 PROSPECT AVE
SYRACUSE NY
13203-1807
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number036719
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: