Healthcare Provider Details

I. General information

NPI: 1104170430
Provider Name (Legal Business Name): MARY MARKERT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2012
Last Update Date: 11/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4850 GLENFIELD DR
SYRACUSE NY
13215-1902
US

IV. Provider business mailing address

4850 GLENFIELD DR
SYRACUSE NY
13215-1902
US

V. Phone/Fax

Practice location:
  • Phone: 315-383-5443
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number304319-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: