=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750487138
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIAN PATRICK DURKIN PA-C, A.T.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 750 E ADAMS ST 4400 UNIVERSITY HOSPITAL
-----------------------------------------------------
City | SYRACUSE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13210-2306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-464-8987
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4551 PROVIDENCE RD
-----------------------------------------------------
City | JAMESVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13078-9806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-492-2830
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | 008984
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------