Healthcare Provider Details

I. General information

NPI: 1811730989
Provider Name (Legal Business Name): MONTANNA J SMITH PNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2024
Last Update Date: 02/25/2026
Certification Date: 02/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6711 TOWPATH RD
EAST SYRACUSE NY
13057-9510
US

IV. Provider business mailing address

6711 TOWPATH RD
EAST SYRACUSE NY
13057-9510
US

V. Phone/Fax

Practice location:
  • Phone: 315-471-2646
  • Fax:
Mailing address:
  • Phone: 315-471-2646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number383826
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: