Healthcare Provider Details

I. General information

NPI: 1366575219
Provider Name (Legal Business Name): JOHN ADAM PROSS PHG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 ARTERIAL RD
SYRACUSE NE
13206
US

IV. Provider business mailing address

3131 HIDDEN LAKE DR
BALDWINSVILLE NY
13027-1529
US

V. Phone/Fax

Practice location:
  • Phone: 315-437-0699
  • Fax: 315-433-9091
Mailing address:
  • Phone: 315-635-0919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number26350
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: