Provider Demographics
NPI:1679562573
Name:FARRELL, PHILLIS B (NP)
Entity Type:Individual
Prefix:
First Name:PHILLIS
Middle Name:B
Last Name:FARRELL
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 1:117 NORTH MECHANIC STREET
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:NY
Mailing Address - Zip Code:13619
Mailing Address - Country:US
Mailing Address - Phone:315-493-3100
Mailing Address - Fax:315-493-3113
Practice Address - Street 1:117 NORTH MECHANIC STREET
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:NY
Practice Address - Zip Code:13619
Practice Address - Country:US
Practice Address - Phone:315-493-3100
Practice Address - Fax:315-493-3113
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF302902-1363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY362748OtherMVP
NY403888001OtherBSNENY
NY362748OtherMVP
DD5062Medicare ID - Type Unspecified