Healthcare Provider Details

I. General information

NPI: 1902999865
Provider Name (Legal Business Name): JEFFERY SCOTT ROY RPA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 IRVING AVE
SYRACUSE NY
13210-2716
US

IV. Provider business mailing address

412 HIGH ST
CANASTOTA NY
13032-1524
US

V. Phone/Fax

Practice location:
  • Phone: 315-425-4400
  • Fax:
Mailing address:
  • Phone: 315-727-8732
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number009043
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: