Healthcare Provider Details

I. General information

NPI: 1316245236
Provider Name (Legal Business Name): MARA A BAZDARIC-RUSSELL FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2011
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 ELM ST
POTSDAM NY
13676-2166
US

IV. Provider business mailing address

50 LEROY ST
POTSDAM NY
13676-1786
US

V. Phone/Fax

Practice location:
  • Phone: 315-353-2572
  • Fax: 315-353-2479
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number336641
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: