Provider Demographics
NPI:1629067061
Name:POVER, CAROLYN MARY (FNP)
Entity Type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:MARY
Last Name:POVER
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 1:104 UNION AVENUE AND TOWNSEND STREET
Mailing Address - Street 2:SUITE 803
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203
Mailing Address - Country:US
Mailing Address - Phone:315-701-5757
Mailing Address - Fax:315-476-8519
Practice Address - Street 1:104 UNION AVENUE AND TOWNSEND STREET
Practice Address - Street 2:SUITE 803
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203
Practice Address - Country:US
Practice Address - Phone:315-701-5757
Practice Address - Fax:315-476-8519
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF3330461207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02127746Medicaid
NY02127746Medicaid
RA7142Medicare ID - Type Unspecified