Healthcare Provider Details

I. General information

NPI: 1992445654
Provider Name (Legal Business Name): JACLYN ELLEN FRANDOLIG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2022
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 N JAMES ST
ROME NY
13440-2899
US

IV. Provider business mailing address

301 PROSPECT AVE
SYRACUSE NY
13203-1807
US

V. Phone/Fax

Practice location:
  • Phone: 315-338-7000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number340489-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: