MEDICARE: MR. AFIX FAMOSA

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	404140	NY
2	363LC1500X	Community Health Nurse Practitioner	320092	NY

General Provider Information

NPI Number	:	1407237647
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. AFIX FAMOSA

Provider Business Mailing Address
First Line	:	1100 IVY RIDGE RD APT 31
Second Line	:
City	:	SYRACUSE
State	:	NY
Zip	:	13210-4129
Country	:	US
Telephone Number	:	347-257-6706
Fax Number	:

Provider Business Practice Location Address
First Line	:	4443 CLEVELAND RD
Second Line	:
City	:	SYRACUSE
State	:	NY
Zip	:	13215-2419
Country	:	US
Telephone Number	:	347-257-6706
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/12/2015
Last Update Date	:	04/15/2024

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Directions to “ MR. AFIX FAMOSA ” Practice Location

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