Provider Demographics
NPI:1376552422
Name:GOODWATER, ELLEN (NP)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:GOODWATER
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 1:357 GENESEE ST STE 2
Mailing Address - Street 2:
Mailing Address - City:ONEIDA
Mailing Address - State:NY
Mailing Address - Zip Code:13421-2658
Mailing Address - Country:US
Mailing Address - Phone:315-363-2123
Mailing Address - Fax:315-363-2821
Practice Address - Street 1:357 GENESEE ST
Practice Address - Street 2:SUITE 2
Practice Address - City:ONEIDA
Practice Address - State:NY
Practice Address - Zip Code:13421-2658
Practice Address - Country:US
Practice Address - Phone:315-363-2123
Practice Address - Fax:315-363-4651
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF331906363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02508276Medicaid
02508276Medicare ID - Type Unspecified
RA0250Medicare ID - Type Unspecified