Healthcare Provider Details

I. General information

NPI: 1003239047
Provider Name (Legal Business Name): JACLYN KORVER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2014
Last Update Date: 01/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 SHONNARD ST
SYRACUSE NY
13204-3216
US

IV. Provider business mailing address

5088 LINCKLAEN RD
CAZENOVIA NY
13035-9749
US

V. Phone/Fax

Practice location:
  • Phone: 315-435-4973
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number668191
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: