Provider Demographics
NPI:1144990672
Name:FOSTER, JEREMY
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:FOSTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 74
Mailing Address - Street 2:
Mailing Address - City:SOUTH OTSELIC
Mailing Address - State:NY
Mailing Address - Zip Code:13155-0074
Mailing Address - Country:US
Mailing Address - Phone:315-571-5128
Mailing Address - Fax:
Practice Address - Street 1:4338 WETZEL RD
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13090-2011
Practice Address - Country:US
Practice Address - Phone:315-453-1500
Practice Address - Fax:315-453-1134
Is Sole Proprietor?:No
Enumeration Date:2021-09-16
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY545399163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool