Healthcare Provider Details

I. General information

NPI: 1417465386
Provider Name (Legal Business Name): KATHRYN B. MORAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2018
Last Update Date: 01/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6575 KIRKVILLE RD
EAST SYRACUSE NY
13057-9809
US

IV. Provider business mailing address

7855 HYACINTH LN
CICERO NY
13039-8331
US

V. Phone/Fax

Practice location:
  • Phone: 315-701-5710
  • Fax:
Mailing address:
  • Phone: 315-440-6961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: