Healthcare Provider Details

I. General information

NPI: 1265042824
Provider Name (Legal Business Name): MADORA DEON MOGENSEN CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MADORA DEON WATERS RN

II. Dates (important events)

Enumeration Date: 08/07/2020
Last Update Date: 08/07/2020
Certification Date: 08/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 E GENESEE ST STE 323
SYRACUSE NY
13202-3108
US

IV. Provider business mailing address

600 E GENESEE ST STE 323
SYRACUSE NY
13202-3108
US

V. Phone/Fax

Practice location:
  • Phone: 315-426-1100
  • Fax: 315-426-1153
Mailing address:
  • Phone: 315-426-1100
  • Fax: 315-426-1153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberF001985
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: