Healthcare Provider Details

I. General information

NPI: 1457273252
Provider Name (Legal Business Name): CRYSTAL TIA SHERMAN AGPCNP-BC
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2026
Last Update Date: 07/27/2026
Certification Date: 07/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3175 COUNTY ROUTE 30 # A
SALEM NY
12865-4103
US

IV. Provider business mailing address

3175 COUNTY ROUTE 30 # A
SALEM NY
12865-4103
US

V. Phone/Fax

Practice location:
  • Phone: 518-223-3986
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF312829-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: