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General NPI Number Information
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NPI Number | 1053789610
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Entity Type | Organization
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Legal Business Name | SUNY UPSTATE
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Dates
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Enumeration Date | 09/11/2015
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Last Update Date | 09/11/2015
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Provider Practice Location Address
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Address Line | 90 PRESIDENTIAL PLZ
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City | SYRACUSE
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State | NY
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Zip | 13202-2240
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Country | US
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Telephone | 315-464-3833
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Fax |
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Provider Business Mailing Address
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Address Line | 5104 WATERFORD WOOD WAY
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City | FAYETTEVILLE
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State | NY
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Zip | 13066-9799
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Country | US
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Telephone | 607-759-7462
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Fax |
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Authorized Official
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Title or Position | FNP
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Name | MRS. VIKTORIA KENNEY
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Credential | FNP
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Telephone | 607-759-7462
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | F339820-1
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License Number State | NY
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