Basic Information
Provider Information | |||||||||
NPI: | 1275813842 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SYRACUSE COMMUNITY HEALTH CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 819 S SALINA ST | ||||||||
Address2: |   | ||||||||
City: | SYRACUSE | ||||||||
State: | NY | ||||||||
PostalCode: | 132023527 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3154767921 | ||||||||
FaxNumber: | 3154751448 | ||||||||
Practice Location | |||||||||
Address1: | 819 S SALINA ST | ||||||||
Address2: |   | ||||||||
City: | SYRACUSE | ||||||||
State: | NY | ||||||||
PostalCode: | 132023527 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3154767921 | ||||||||
FaxNumber: | 3154751448 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/26/2011 | ||||||||
LastUpdateDate: | 08/26/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PARKER | ||||||||
AuthorizedOfficialFirstName: | DAVIDA | ||||||||
AuthorizedOfficialMiddleName: | F | ||||||||
AuthorizedOfficialTitleorPosition: | NURSE PRACTITIONER | ||||||||
AuthorizedOfficialTelephone: | 3154767921 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | FNP | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | F336806-1 | NY | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Community Health |
No ID Information.