Basic Information
| Provider Information | |||||||||
| NPI: | 1902105273 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FETZER | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2337 | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132202337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154226705 | ||||||||
| FaxNumber: | 3154223909 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 GREENFIELD PKWY STE 105 | ||||||||
| Address2: | |||||||||
| City: | LIVERPOOL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154516911 | ||||||||
| FaxNumber: | 3154511540 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2011 | ||||||||
| LastUpdateDate: | 10/31/2019 | ||||||||
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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 | 367500000X | 543801 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.