Provider Demographics
NPI:1598803678
Name:BOGAN, PATRICE ANNE (NP)
Entity Type:Individual
Prefix:MS
First Name:PATRICE
Middle Name:ANNE
Last Name:BOGAN
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 1:185 GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-2102
Mailing Address - Country:US
Mailing Address - Phone:315-798-5080
Mailing Address - Fax:315-798-5022
Practice Address - Street 1:406 ELIZABETH ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-2306
Practice Address - Country:US
Practice Address - Phone:315-798-5747
Practice Address - Fax:315-798-1057
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF-333395363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400032648Medicare PIN