Provider Demographics
NPI:1114303278
Name:DETOR, CARLY (NP)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:DETOR
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 UNION AVE
Mailing Address - Street 2:SUITE 1001-1002
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203-1843
Mailing Address - Country:US
Mailing Address - Phone:315-423-7192
Mailing Address - Fax:315-423-8013
Practice Address - Street 1:104 UNION AVE
Practice Address - Street 2:SUITE 1001-1002
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-1843
Practice Address - Country:US
Practice Address - Phone:315-423-7192
Practice Address - Fax:315-423-8013
Is Sole Proprietor?:No
Enumeration Date:2015-07-30
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY339796363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner