Provider Demographics
NPI:1093718066
Name:SERVAGE, BONNIE L (ANP)
Entity Type:Individual
Prefix:MISS
First Name:BONNIE
Middle Name:L
Last Name:SERVAGE
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53-59 PUBLIC SQ
Mailing Address - Street 2:STE 301
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-2674
Mailing Address - Country:US
Mailing Address - Phone:315-782-2141
Mailing Address - Fax:315-782-5123
Practice Address - Street 1:53-59 PUBLIC SQ
Practice Address - Street 2:STE 301
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-2674
Practice Address - Country:US
Practice Address - Phone:315-782-2141
Practice Address - Fax:315-782-5123
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF303309363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02331175Medicaid
NY7599474OtherGHI
NYDD3908Medicare PIN
NYDD3908Medicare ID - Type Unspecified
NY02331175Medicaid