Provider Demographics
NPI:1164865739
Name:PEREZ, JAYSON BRUCE (FNP)
Entity Type:Individual
Prefix:
First Name:JAYSON
Middle Name:BRUCE
Last Name:PEREZ
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1127 E GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1911
Mailing Address - Country:US
Mailing Address - Phone:315-473-4266
Mailing Address - Fax:315-473-6037
Practice Address - Street 1:1127 E GENESEE ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1911
Practice Address - Country:US
Practice Address - Phone:315-473-4266
Practice Address - Fax:315-473-6037
Is Sole Proprietor?:No
Enumeration Date:2013-04-12
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY337983363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03638795Medicaid
NYJ400106502Medicare PIN