MEDICARE: SOUTHERN TIER FAMILY NURSE PRACTITIONER SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician
2	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1396492369
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN TIER FAMILY NURSE PRACTITIONER SERVICES

Provider Business Mailing Address
First Line	:	520 COLUMBIA DR STE 203
Second Line	:
City	:	JOHNSON CITY
State	:	NY
Zip	:	13790-3305
Country	:	US
Telephone Number	:	607-677-0011
Fax Number	:

Provider Business Practice Location Address
First Line	:	520 COLUMBIA DR STE 203
Second Line	:
City	:	JOHNSON CITY
State	:	NY
Zip	:	13790-3305
Country	:	US
Telephone Number	:	607-677-0011
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DANIEL BABCOCK
Credential	:	FNP-C
Telephone Number	:	607-677-0011

Provider Enumeration Date	:	03/09/2022
Last Update Date	:	03/09/2022

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