MEDICARE: DYLAN L JUDA PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	026046	NY

General Provider Information

NPI Number	:	1407452709
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DYLAN L JUDA PA

Provider Business Mailing Address
First Line	:	6846 BUCKLEY RD STE 1
Second Line	:
City	:	NORTH SYRACUSE
State	:	NY
Zip	:	13212-4270
Country	:	US
Telephone Number	:	315-410-6400
Fax Number	:

Provider Business Practice Location Address
First Line	:	6846 BUCKLEY RD STE 1
Second Line	:
City	:	NORTH SYRACUSE
State	:	NY
Zip	:	13212-4270
Country	:	US
Telephone Number	:	315-410-6400
Fax Number	:	315-410-6410

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/10/2020
Last Update Date	:	12/10/2020

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