Provider Demographics
NPI:1174664056
Name:WASHO, MICHAEL J (CDN)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:WASHO
Suffix:
Gender:M
Credentials:CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 JUNIPER LN
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13219-2115
Mailing Address - Country:US
Mailing Address - Phone:315-829-8700
Mailing Address - Fax:
Practice Address - Street 1:2 TERRITORY RD
Practice Address - Street 2:
Practice Address - City:ONEIDA
Practice Address - State:NY
Practice Address - Zip Code:13421-9304
Practice Address - Country:US
Practice Address - Phone:315-829-8700
Practice Address - Fax:315-829-8731
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY02620133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered