Provider Demographics
NPI:1558663856
Name:FAGER, JUDITH HUNTER (PHD, RN, PMHNP)
Entity Type:Individual
Prefix:DR
First Name:JUDITH
Middle Name:HUNTER
Last Name:FAGER
Suffix:
Gender:F
Credentials:PHD, RN, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
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Mailing Address - Street 1:5900 N BURDICK ST STE 206A
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-9464
Mailing Address - Country:US
Mailing Address - Phone:315-627-0383
Mailing Address - Fax:731-202-0964
Practice Address - Street 1:5900 N BURDICK ST STE 206A
Practice Address - Street 2:
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-9464
Practice Address - Country:US
Practice Address - Phone:315-627-0383
Practice Address - Fax:731-202-0964
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-19
Last Update Date:2020-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF3000731363LA2200X
NYF3313801363LF0000X
NYF401699363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00355266Medicaid
NY00355266Medicaid