Basic Information
| Provider Information | |||||||||
| NPI: | 1104061217 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROTON | ||||||||
| FirstName: | WENDY | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 90 PRESIDENTIAL PLZ | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132022240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154644357 | ||||||||
| FaxNumber: | 3154647564 | ||||||||
| Practice Location | |||||||||
| Address1: | 90 PRESIDENTIAL PLZ | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132022240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154644357 | ||||||||
| FaxNumber: | 3154647564 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2008 | ||||||||
| LastUpdateDate: | 08/30/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 335618 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 03056388 | 05 | NY | MEDICAID |