Provider Demographics
NPI:1043374739
Name:BYRNES, EILIS WAGNER (PA)
Entity type:Individual
Prefix:
First Name:EILIS
Middle Name:WAGNER
Last Name:BYRNES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 BOYD AVE
Mailing Address - Street 2:
Mailing Address - City:CHITTENANGO
Mailing Address - State:NY
Mailing Address - Zip Code:13037-1244
Mailing Address - Country:US
Mailing Address - Phone:315-560-1799
Mailing Address - Fax:
Practice Address - Street 1:109 GENESEE ST
Practice Address - Street 2:
Practice Address - City:ONEIDA
Practice Address - State:NY
Practice Address - Zip Code:13421-2703
Practice Address - Country:US
Practice Address - Phone:315-231-5530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.007310RX363A00000X
MI5601010832363A00000X
IL085.007620363A00000X
IN10003641A363A00000X
NY009614363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02524418Medicaid
NYJ400218676OtherMEDICARE PTAN
NYJ400042295Medicare PIN