MEDICARE: AMANDA LEE MCDERMOTT

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	363LF0000X	Family Nurse Practitioner	347686	NY

General Provider Information

NPI Number	:	1912661505
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA LEE MCDERMOTT

Provider Business Mailing Address
First Line	:	105 SCOTT LN
Second Line	:
City	:	LIVERPOOL
State	:	NY
Zip	:	13088-5433
Country	:	US
Telephone Number	:	315-663-5145
Fax Number	:

Provider Business Practice Location Address
First Line	:	104 UNION AVE STE 904
Second Line	:
City	:	SYRACUSE
State	:	NY
Zip	:	13203-1845
Country	:	US
Telephone Number	:	315-703-5108
Fax Number	:

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

Provider Enumeration Date	:	10/28/2021
Last Update Date	:	10/28/2021

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