Provider Demographics
NPI:1558352260
Name:BOTSFORD, MARY (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:BOTSFORD
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 1:1001 W FAYETTE ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13204-2856
Mailing Address - Country:US
Mailing Address - Phone:315-472-1488
Mailing Address - Fax:315-472-8060
Practice Address - Street 1:792 N MAIN ST
Practice Address - Street 2:SUITE 200A
Practice Address - City:NORTH SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13212-1644
Practice Address - Country:US
Practice Address - Phone:315-458-8700
Practice Address - Fax:315-701-1075
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF300701363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCC3912Medicare ID - Type Unspecified
NYP02318Medicare UPIN