Provider Demographics
NPI:1003678020
Name:ST ONGE, AUDRA RENEE
Entity type:Individual
Prefix:MS
First Name:AUDRA
Middle Name:RENEE
Last Name:ST ONGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AUDRA
Other - Middle Name:
Other - Last Name:ST. ONGE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:427 GUY PARK AVE
Mailing Address - Street 2:
Mailing Address - City:AMSTERDAM
Mailing Address - State:NY
Mailing Address - Zip Code:12010-1064
Mailing Address - Country:US
Mailing Address - Phone:518-842-1900
Mailing Address - Fax:
Practice Address - Street 1:427 GUY PARK AVE
Practice Address - Street 2:
Practice Address - City:AMSTERDAM
Practice Address - State:NY
Practice Address - Zip Code:12010-1064
Practice Address - Country:US
Practice Address - Phone:518-842-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-25
Last Update Date:2025-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY031854-01363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program