Provider Demographics
NPI:1043793854
Name:MARCY, AUTUMN LYNN (PA-C)
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:LYNN
Last Name:MARCY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AUTUMN
Other - Middle Name:LYNN
Other - Last Name:CUNNINGHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2 COULTER ROAD
Mailing Address - Street 2:SUITE 2100
Mailing Address - City:CLIFTON SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:14432
Mailing Address - Country:US
Mailing Address - Phone:315-462-9561
Mailing Address - Fax:315-462-0561
Practice Address - Street 1:2 COULTER ROAD
Practice Address - Street 2:SUITE 2100
Practice Address - City:CLIFTON SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:14432
Practice Address - Country:US
Practice Address - Phone:315-462-9561
Practice Address - Fax:315-462-0561
Is Sole Proprietor?:No
Enumeration Date:2018-09-09
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022438363A00000X, 363AM0700X
PAMA065512363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05429483Medicaid