Basic Information
| Provider Information | |||||||||
| NPI: | 1316603855 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PTAK | ||||||||
| FirstName: | SHEILA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3187 BELLEVUE AVE APT B7 | ||||||||
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| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132193162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6179433819 | ||||||||
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| Practice Location | |||||||||
| Address1: | 90 PRESIDENTIAL PLZ | ||||||||
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| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132022240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154645357 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2021 | ||||||||
| LastUpdateDate: | 11/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080A0000X | 383311 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine |
No ID Information.