Healthcare Provider Details

I. General information

NPI: 1942804547
Provider Name (Legal Business Name): BRENNA M EISENBERG PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2020
Last Update Date: 04/08/2024
Certification Date: 03/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 PRESIDENTIAL PLAZA
SYRACUSE NY
13202
US

IV. Provider business mailing address

251 SALINA MEADOWS PARKWAY SUITE 100
SYRACUSE NY
13212
US

V. Phone/Fax

Practice location:
  • Phone: 315-464-4243
  • Fax: 315-464-7328
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 Number026062
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier06422857
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: