Provider Demographics
NPI:1326011305
Name:BOUSHIE, CYNTHIA M (NP)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:M
Last Name:BOUSHIE
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 1:5415 W GENESEE ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:CAMILLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13031-2162
Mailing Address - Country:US
Mailing Address - Phone:315-487-8109
Mailing Address - Fax:
Practice Address - Street 1:5415 W GENESEE ST
Practice Address - Street 2:SUITE 301
Practice Address - City:CAMILLUS
Practice Address - State:NY
Practice Address - Zip Code:13031-2162
Practice Address - Country:US
Practice Address - Phone:315-487-8109
Practice Address - Fax:315-487-5680
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF3327451363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02708547Medicaid
NY02708547Medicaid
NYRA9900Medicare ID - Type Unspecified