Provider Demographics
NPI:1558394023
Name:WOOD, ROBERTA L (NP)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:L
Last Name:WOOD
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 1:111 E 14TH ST
Mailing Address - Street 2:
Mailing Address - City:ELMIRA HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:14903-1303
Mailing Address - Country:US
Mailing Address - Phone:607-734-9539
Mailing Address - Fax:607-734-6293
Practice Address - Street 1:290 E 1ST ST
Practice Address - Street 2:SUITE 1
Practice Address - City:CORNING
Practice Address - State:NY
Practice Address - Zip Code:14830-2925
Practice Address - Country:US
Practice Address - Phone:607-936-1244
Practice Address - Fax:607-936-4023
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY332692363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS82473Medicare UPIN
NYRA6466Medicare ID - Type Unspecified