Healthcare Provider Details

I. General information

NPI: 1952475527
Provider Name (Legal Business Name): SHIRLEY J ODDY NP PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 06/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050 TILDEN AVE
NEW HARTFORD NY
13413-3613
US

IV. Provider business mailing address

2050 TILDEN AVE
NEW HARTFORD NY
13413-3613
US

V. Phone/Fax

Practice location:
  • Phone: 315-737-2285
  • Fax:
Mailing address:
  • Phone: 315-737-2285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberF300058-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number002125
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: