MEDICARE: MRS. KRISTINE A. CERVANTES LPT

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	225100000X	Physical Therapist	030277	NY
2	225100000X	Physical Therapist	9026	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	013X1	OTHER	NC	BCBS GROUP PROV. #
2	079FC	OTHER	NC	BCBS INDIV PROVIDER #
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1871647636
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KRISTINE A. CERVANTES LPT

Provider Business Mailing Address
First Line	:	7960 JOSS FARM WAY
Second Line	:
City	:	CICERO
State	:	NY
Zip	:	13039
Country	:	US
Telephone Number	:	910-584-8571
Fax Number	:

Provider Business Practice Location Address
First Line	:	2949 ERIE BLVD E
Second Line	:
City	:	SYRACUSE
State	:	NY
Zip	:	13224-1442
Country	:	US
Telephone Number	:	315-251-1036
Fax Number	:

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

Provider Enumeration Date	:	01/22/2007
Last Update Date	:	10/01/2008

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Directions to “ MRS. KRISTINE A. CERVANTES LPT” Practice Location

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