Healthcare Provider Details

I. General information

NPI: 1942331475
Provider Name (Legal Business Name): KIMBERLY FOX MAHR CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 HARRISON ST SUITE 230
SYRACUSE NY
13202-3096
US

IV. Provider business mailing address

416 CHURCHILL LN
FAYETTEVILLE NY
13066-2543
US

V. Phone/Fax

Practice location:
  • Phone: 315-472-4424
  • Fax: 315-475-8056
Mailing address:
  • Phone: 315-682-4236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number442937
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: