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General NPI Number Information
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NPI Number | 1669662771
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Entity Type | Organization
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Legal Business Name | MOBILE NP-ADULT HEALTH OF CNY, P.C.
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Dates
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Enumeration Date | 07/26/2007
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Last Update Date | 07/26/2007
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Provider Practice Location Address
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Address Line | 124 RUGBY RD
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City | SYRACUSE
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State | NY
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Zip | 13206-3225
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Country | US
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Telephone | 315-437-1693
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Fax |
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Provider Business Mailing Address
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Address Line | 124 RUGBY RD
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City | SYRACUSE
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State | NY
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Zip | 13206-3225
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MS. DESTA ANTHONY
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Credential |
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Telephone | 315-437-1693
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number | 303332
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License Number State | NY
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