Provider Demographics
NPI:1508948167
Name:NELLIS, STEPHEN MICHAEL (PT)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:MICHAEL
Last Name:NELLIS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 PINE ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1137
Mailing Address - Country:US
Mailing Address - Phone:315-476-3176
Mailing Address - Fax:315-476-0171
Practice Address - Street 1:3400 SENECA TPKE STE 7
Practice Address - Street 2:
Practice Address - City:CANASTOTA
Practice Address - State:NY
Practice Address - Zip Code:13032-4632
Practice Address - Country:US
Practice Address - Phone:315-697-8514
Practice Address - Fax:315-697-8147
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY17733174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS83110Medicare UPIN