Basic Information
| Provider Information | |||||||||
| NPI: | 1629082425 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SECOR | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FRATANGELO | ||||||||
| OtherFirstName: | AMY | ||||||||
| OtherMiddleName: | ANNE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | FNP | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 821 PRE EMPTION RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | GENEVA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 144562061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157875310 | ||||||||
| FaxNumber: | 3157875314 | ||||||||
| Practice Location | |||||||||
| Address1: | 17 E GENESEE ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | AUBURN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130214112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3152535151 | ||||||||
| FaxNumber: | 3152530841 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 03/19/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | F3322911 | NY | N | Allopathic & Osteopathic Physicians | Family Medicine | 207RG0100X | F332291-1 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 363L00000X | F332291-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 01877930 | 05 | NY | MEDICAID |