Basic Information
| Provider Information | |||||||||
| NPI: | 1881948107 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUTAGARAMA | ||||||||
| FirstName: | YVONNE | ||||||||
| MiddleName: | U. | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 819 S SALINA ST | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132023527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154767921 | ||||||||
| FaxNumber: | 3157471448 | ||||||||
| Practice Location | |||||||||
| Address1: | 819 S SALINA ST | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132023527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154767921 | ||||||||
| FaxNumber: | 3154751448 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2012 | ||||||||
| LastUpdateDate: | 03/30/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 337419 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 03530045 | 05 | NY | MEDICAID |