=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679482665
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | COURTNEY WALDRON FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2026
-----------------------------------------------------
Last Update Date | 09/04/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5000 BRITTONFIELD PKWY
-----------------------------------------------------
City | EAST SYRACUSE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13057-9226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-499-3800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110 AQUA WAY
-----------------------------------------------------
City | CENTRAL SQUARE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13036-2637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 357482
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------