Basic Information
| Provider Information | |||||||||
| NPI: | 1801330105 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HASKINS | ||||||||
| FirstName: | ADRIENNE | ||||||||
| MiddleName: | AMANDA | ||||||||
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| Credential: | RSA/RPA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1571 WASHINGTON ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136019304 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1571 WASHINGTON ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136019304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157865000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2016 | ||||||||
| LastUpdateDate: | 04/11/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 243U00000X | 13OK1472 | OK | Y | Technologists, Technicians & Other Technical Service Providers | Radiology Practitioner Assistant |
No ID Information.