Basic Information
Provider Information | |||||||||
NPI: | 1679550552 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BARTER | ||||||||
FirstName: | PAUL | ||||||||
MiddleName: | D | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 428 WASHINGTON ST | ||||||||
Address2: | STE 4 | ||||||||
City: | WATERTOWN | ||||||||
State: | NY | ||||||||
PostalCode: | 136014832 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3157884880 | ||||||||
FaxNumber: | 3157884896 | ||||||||
Practice Location | |||||||||
Address1: | 428 WASHINGTON ST | ||||||||
Address2: | STE 4 | ||||||||
City: | WATERTOWN | ||||||||
State: | NY | ||||||||
PostalCode: | 136014832 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3157884880 | ||||||||
FaxNumber: | 3157884896 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/30/2005 | ||||||||
LastUpdateDate: | 11/22/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F3314201 | NY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 01777691 | 05 | NY |   | MEDICAID |