Healthcare Provider Details

I. General information

NPI: 1902893126
Provider Name (Legal Business Name): JUDITH B DYNE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 04/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E GENESEE ST STE 300
SYRACUSE NY
13210-1892
US

IV. Provider business mailing address

1000 E GENESEE ST STE 300
SYRACUSE NY
13210-1892
US

V. Phone/Fax

Practice location:
  • Phone: 315-471-1044
  • Fax: 315-474-4312
Mailing address:
  • Phone: 315-471-1044
  • Fax: 315-474-4312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberF301606
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: