Healthcare Provider Details

I. General information

NPI: 1184726341
Provider Name (Legal Business Name): MARY ELIZABETH MACBLANE PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 E ADAMS ST PEDIATRICS
SYRACUSE NY
13210-2306
US

IV. Provider business mailing address

5235 BEAR RD
NORTH SYRACUSE NY
13212-1213
US

V. Phone/Fax

Practice location:
  • Phone: 315-464-5259
  • Fax: 315-464-6398
Mailing address:
  • Phone: 315-464-5259
  • Fax: 315-464-6398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number325340-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberF380760-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: