Healthcare Provider Details

I. General information

NPI: 1700297918
Provider Name (Legal Business Name): DIANA RASMUSSEN NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2014
Last Update Date: 05/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46 HARRISON ST SOUTHERN NEW YORK NEUROSURGICAL GROUP, P.C.
JOHNSON CITY NY
13790-2120
US

IV. Provider business mailing address

46 HARRISON ST SOUTHERN NEW YORK NEUROSURGICAL GROUP, P.C.
JOHNSON CITY NY
13790-2120
US

V. Phone/Fax

Practice location:
  • Phone: 607-729-4942
  • Fax: 607-729-7516
Mailing address:
  • Phone: 607-729-4942
  • Fax: 607-729-7516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number338475
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP013837
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: