Provider Demographics
NPI:1417622135
Name:CENTRAL NEW YORK FAMILY HEALTH NURSE PRACTITIONER PLLC
Entity Type:Organization
Organization Name:CENTRAL NEW YORK FAMILY HEALTH NURSE PRACTITIONER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MIDZY
Authorized Official - Middle Name:
Authorized Official - Last Name:LYSIUS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:315-876-5748
Mailing Address - Street 1:6303 YULEWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:NY
Mailing Address - Zip Code:13039-9251
Mailing Address - Country:US
Mailing Address - Phone:315-876-5748
Mailing Address - Fax:
Practice Address - Street 1:5701 E. CIRCLE DR.
Practice Address - Street 2:#264 SUITE 108
Practice Address - City:CICERO
Practice Address - State:NY
Practice Address - Zip Code:13039
Practice Address - Country:US
Practice Address - Phone:315-876-5748
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-13
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service