Healthcare Provider Details

I. General information

NPI: 1114685468
Provider Name (Legal Business Name): COREY ADAM SCOFIELD CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2021
Last Update Date: 12/03/2021
Certification Date: 12/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1656 CHAMPLIN AVE
UTICA NY
13502-4830
US

IV. Provider business mailing address

9633 MAYNARD DR
MARCY NY
13403-2233
US

V. Phone/Fax

Practice location:
  • Phone: 315-624-6000
  • Fax:
Mailing address:
  • Phone: 518-775-0394
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number720924-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: