Provider Demographics
NPI:1629710439
Name:ADAMS, SHICOREN M I (YPA CREDIENTIAL)
Entity Type:Individual
Prefix:
First Name:SHICOREN
Middle Name:M
Last Name:ADAMS
Suffix:I
Gender:M
Credentials:YPA CREDIENTIAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 WYOMING ST STE 202
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13204-2928
Mailing Address - Country:US
Mailing Address - Phone:315-406-8564
Mailing Address - Fax:
Practice Address - Street 1:215 WYOMING ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13204-2927
Practice Address - Country:US
Practice Address - Phone:315-703-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-12
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY175T00000XMedicaid