MEDICARE: KAREN LYNN RAEDER FNP

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	363LF0000X	Family Nurse Practitioner	33 336388	NY
2	363L00000X	Nurse Practitioner	33 336388	NY

General Provider Information

NPI Number	:	1649582354
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAREN LYNN RAEDER FNP

Provider Business Mailing Address
First Line	:	300 SOUTH RD.
Second Line	:	MACORMICK SECURE CENTER
City	:	BROOKTONDALE
State	:	NY
Zip	:	14817
Country	:	US
Telephone Number	:	607-539-7121
Fax Number	:

Provider Business Practice Location Address
First Line	:	300 SOUTH RD
Second Line	:
City	:	BROOKTONDALE
State	:	NY
Zip	:	14817-9722
Country	:	US
Telephone Number	:	607-539-7121
Fax Number	:

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

Provider Enumeration Date	:	07/10/2010
Last Update Date	:	09/02/2016

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