=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538890157
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LIYA THOMAS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2022
-----------------------------------------------------
Last Update Date | 01/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7040 MANLIUS CENTER RD
-----------------------------------------------------
City | EAST SYRACUSE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13057-9530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-478-1100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 118 STRATTFORD RD
-----------------------------------------------------
City | NEW HYDE PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11040-3513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-590-8712
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 030995
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------