Basic Information
Provider Information | |||||||||
NPI: | 1063540060 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VINCENTINI | ||||||||
FirstName: | EMILY | ||||||||
MiddleName: | ELIZABETH | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LOPEZ | ||||||||
OtherFirstName: | EMILY | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 104 UNION AVE | ||||||||
Address2: | SUITE 1005 | ||||||||
City: | SYRACUSE | ||||||||
State: | NY | ||||||||
PostalCode: | 13203 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3154240790 | ||||||||
FaxNumber: | 3154750916 | ||||||||
Practice Location | |||||||||
Address1: | 104 UNION AVE | ||||||||
Address2: | SUITE 1005 | ||||||||
City: | SYRACUSE | ||||||||
State: | NY | ||||||||
PostalCode: | 13203 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3154240790 | ||||||||
FaxNumber: | 3154750916 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/01/2007 | ||||||||
LastUpdateDate: | 10/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/21/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 011696-1 | NY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.