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General NPI Number Information
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NPI Number | 1073522587
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Entity Type | Individual
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Provider Name | BRENDA R VAN FOSSEN MD
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Gender | Female
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Dates
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Enumeration Date | 08/05/2006
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Last Update Date | 03/22/2018
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Provider Practice Location Address
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Address Line | 7375 OSWEGO RD
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City | LIVERPOOL
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State | NY
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Zip | 13090-3717
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Country | US
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Telephone | 315-291-0064
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Fax | 315-291-0065
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Provider Business Mailing Address
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Address Line | PO BOX 500
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City | ELLICOTTVILLE
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State | NY
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Zip | 14731-0500
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Country | US
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Telephone | 716-699-9032
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Fax | 716-699-9035
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | MD00043720
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 291334
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License Number State | NY
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