Provider Demographics
NPI:1033134614
Name:HEAGLE BAHN, CHRISTINE (NP)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:HEAGLE BAHN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:CHRISTINE
Other - Middle Name:
Other - Last Name:HEAGLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:550 HARRISON ST
Mailing Address - Street 2:STE 117
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13202-3188
Mailing Address - Country:US
Mailing Address - Phone:315-464-6100
Mailing Address - Fax:315-464-9245
Practice Address - Street 1:550 HARRISON ST
Practice Address - Street 2:STE 117
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-3188
Practice Address - Country:US
Practice Address - Phone:315-464-6100
Practice Address - Fax:315-464-9245
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY300421363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02118069Medicaid
NYP500015838Medicare PIN
NY02118069Medicaid