Healthcare Provider Details

I. General information

NPI: 1770263170
Provider Name (Legal Business Name): MEGAN RIDDICK FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2023
Last Update Date: 10/16/2023
Certification Date: 07/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 IRVING AVE STE 600
SYRACUSE NY
13210-1688
US

IV. Provider business mailing address

725 IRVING AVE SUITE 600
SYRACUSE NY
13210-1688
US

V. Phone/Fax

Practice location:
  • Phone: 315-464-5162
  • Fax:
Mailing address:
  • Phone: 315-464-5162
  • Fax: 315-464-2122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberF352307-01
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number352307
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number352307
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: