MEDICARE: MR. WARD IRVIN JR. 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	019415	NY
2	363AM0700X	Medical Physician Assistant	019415	NY
3	363AS0400X	Surgical Physician Assistant	019415	NY

General Provider Information

NPI Number	:	1831555747
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. WARD IRVIN JR. PA

Provider Business Mailing Address
First Line	:	104 UNION AVE STE 908
Second Line	:
City	:	SYRACUSE
State	:	NY
Zip	:	13203-1845
Country	:	US
Telephone Number	:	315-425-0860
Fax Number	:

Provider Business Practice Location Address
First Line	:	104 UNION AVE STE 908
Second Line	:
City	:	SYRACUSE
State	:	NY
Zip	:	13203-1845
Country	:	US
Telephone Number	:	315-425-0860
Fax Number	:

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

Provider Enumeration Date	:	01/07/2016
Last Update Date	:	01/07/2016

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