Basic Information
| Provider Information | |||||||||
| NPI: | 1619240249 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIZON | ||||||||
| FirstName: | EMMA | ||||||||
| MiddleName: | DAYANGCO | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 60 MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | PORT BYRON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 131400359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157769700 | ||||||||
| FaxNumber: | 3157769701 | ||||||||
| Practice Location | |||||||||
| Address1: | 161 GENESEE ST STE 203 | ||||||||
| Address2: | |||||||||
| City: | AUBURN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130213498 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3152550947 | ||||||||
| FaxNumber: | 3152550942 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2012 | ||||||||
| LastUpdateDate: | 08/03/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F336078-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 03508490 | 05 | NY | MEDICAID |