Basic Information
| Provider Information | |||||||||
| NPI: | 1184726341 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACBLANE | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | PNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5235 BEAR RD | ||||||||
| Address2: | |||||||||
| City: | NORTH SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132121213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154645259 | ||||||||
| FaxNumber: | 3154646398 | ||||||||
| Practice Location | |||||||||
| Address1: | 750 E ADAMS ST | ||||||||
| Address2: | PEDIATRICS | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132102306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154645259 | ||||||||
| FaxNumber: | 3154646398 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0200X | 325340-1 | NY | X | Nursing Service Providers | Registered Nurse | Pediatrics | 363LP0200X | F380760-1 | NY | X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 02218940 | 05 | NY | MEDICAID |