Healthcare Provider Details

I. General information

NPI: 1407859622
Provider Name (Legal Business Name): GEORGE LEE MARKWARDT NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 02/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 CENTRAL PLZ
ILION NY
13357-1701
US

IV. Provider business mailing address

55 CENTRAL PLZ
ILION NY
13357-1701
US

V. Phone/Fax

Practice location:
  • Phone: 315-894-0071
  • Fax: 315-894-0078
Mailing address:
  • Phone: 315-894-0071
  • Fax: 315-894-0078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number334948
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number460581
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: