Healthcare Provider Details

I. General information

NPI: 1134053572
Provider Name (Legal Business Name): KATHLEEN ELIZABETH WANDELL PA-S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2026
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 E ADAMS ST
SYRACUSE NY
13210-1834
US

IV. Provider business mailing address

4378 GEORGIAN CT APT A15
LIVERPOOL NY
13090-3993
US

V. Phone/Fax

Practice location:
  • Phone: 315-464-5540
  • Fax:
Mailing address:
  • Phone: 607-731-8789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: