Healthcare Provider Details

I. General information

NPI: 1285244277
Provider Name (Legal Business Name): PAYTON MARYJEAN HANNON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2020
Last Update Date: 07/29/2021
Certification Date: 07/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 PARKWAY DR
COBLESKILL NY
12043-5150
US

IV. Provider business mailing address

136 PARKWAY DR
COBLESKILL NY
12043-5150
US

V. Phone/Fax

Practice location:
  • Phone: 518-234-2555
  • Fax: 518-234-2555
Mailing address:
  • Phone: 315-625-4034
  • Fax: 518-234-3415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number347770
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number347770
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: