Healthcare Provider Details

I. General information

NPI: 1841918000
Provider Name (Legal Business Name): JESSICA T LIVESEY PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2022
Last Update Date: 04/07/2024
Certification Date: 04/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 PROSPECT AVE
SYRACUSE NY
13203-1807
US

IV. Provider business mailing address

301 PROSPECT AVE
SYRACUSE NY
13203-1807
US

V. Phone/Fax

Practice location:
  • Phone: 315-448-6188
  • Fax: 315-703-2403
Mailing address:
  • Phone: 315-448-6188
  • Fax: 315-703-2403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number028634
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: