MEDICARE: ELISABETH KUSIAK PA-C

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	363AM0700X	Medical Physician Assistant
2	363A00000X	Physician Assistant	033121	NY

General Provider Information

NPI Number	:	1588229926
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELISABETH KUSIAK PA-C

Provider Business Mailing Address
First Line	:	PO BOX 14890
Second Line	:
City	:	ALBANY
State	:	NY
Zip	:	12212-4890
Country	:	US
Telephone Number	:	518-999-9999
Fax Number	:	518-649-4094

Provider Business Practice Location Address
First Line	:	31 LOWER HUDSON AVE
Second Line	:
City	:	GREEN ISLAND
State	:	NY
Zip	:	12183-1014
Country	:	US
Telephone Number	:	518-272-9140
Fax Number	:	518-272-9145

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

Provider Enumeration Date	:	05/01/2019
Last Update Date	:	02/10/2025

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