Provider Demographics
NPI:1093293383
Name:MANUEL, BILLY (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:BILLY
Middle Name:
Last Name:MANUEL
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4396 GEORGIAN CT APT 27
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13090-3889
Mailing Address - Country:US
Mailing Address - Phone:678-428-3647
Mailing Address - Fax:
Practice Address - Street 1:620 ERIE BLVD W STE 302
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13204-2463
Practice Address - Country:US
Practice Address - Phone:315-472-7363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-30
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY684280163W00000X
NY402391363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse