Basic Information
| Provider Information | |||||||||
| NPI: | 1750346540 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHALLER | ||||||||
| FirstName: | MARGE | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | RPA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 346 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077700025 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1302 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ENDICOTT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077547171 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 0039241 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 02149080 | 05 | NY | MEDICAID |