Healthcare Provider Details

I. General information

NPI: 1477876886
Provider Name (Legal Business Name): MARTHA L GONYEA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARTHA L HARRIS

II. Dates (important events)

Enumeration Date: 03/12/2010
Last Update Date: 03/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 W GENESEE ST
SYRACUSE NY
13204-2215
US

IV. Provider business mailing address

1050 W GENESEE ST
SYRACUSE NY
13204-2215
US

V. Phone/Fax

Practice location:
  • Phone: 315-424-3744
  • Fax: 315-424-3745
Mailing address:
  • Phone: 315-424-3744
  • Fax: 315-424-3745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number22-226444
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: