Basic Information
| Provider Information | |||||||||
| NPI: | 1528297371 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BELANGER | ||||||||
| FirstName: | EVAN | ||||||||
| MiddleName: | HARRIS | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | FNP, RNFA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 W FAYETTE ST | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132042859 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154753999 | ||||||||
| FaxNumber: | 3154704014 | ||||||||
| Practice Location | |||||||||
| Address1: | 739 IRVING AVE STE 600 | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132101663 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157012550 | ||||||||
| FaxNumber: | 3157012551 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2009 | ||||||||
| LastUpdateDate: | 03/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F335951-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 03210684 | 05 | NY | MEDICAID |