Healthcare Provider Details

I. General information

NPI: 1295193332
Provider Name (Legal Business Name): JESSICA WAGENBLATT NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2016
Last Update Date: 04/15/2020
Certification Date: 04/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 E ADAMS ST
SYRACUSE NY
13210-2306
US

IV. Provider business mailing address

11 GETTMAN DR
BALDWINSVILLE NY
13027-9491
US

V. Phone/Fax

Practice location:
  • Phone: 315-464-2500
  • Fax:
Mailing address:
  • Phone: 860-307-2106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF340140
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: