Provider Demographics
NPI:1619240249
Name:DIZON, EMMA DAYANGCO (FNP)
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:DAYANGCO
Last Name:DIZON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:PORT BYRON
Mailing Address - State:NY
Mailing Address - Zip Code:13140-0359
Mailing Address - Country:US
Mailing Address - Phone:315-776-9700
Mailing Address - Fax:315-776-9701
Practice Address - Street 1:161 GENESEE ST STE 203
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021-3498
Practice Address - Country:US
Practice Address - Phone:315-255-0947
Practice Address - Fax:315-255-0942
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-13
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF336078-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03508490Medicaid