Healthcare Provider Details

I. General information

NPI: 1508558990
Provider Name (Legal Business Name): LEONARD DEWAYNE HURTEAU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2023
Last Update Date: 05/23/2023
Certification Date: 05/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4797 COUNTRYSIDE DR
SYRACUSE NY
13215-9703
US

IV. Provider business mailing address

4797 COUNTRYSIDE DR
SYRACUSE NY
13215-9703
US

V. Phone/Fax

Practice location:
  • Phone: 315-345-0564
  • Fax:
Mailing address:
  • Phone: 315-345-0564
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF334672-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: