Provider Demographics
NPI:1740204759
Name:LUPO, LINDA SUE (NP)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:SUE
Last Name:LUPO
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 1:37 W GARDEN ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021-2662
Mailing Address - Country:US
Mailing Address - Phone:315-567-0777
Mailing Address - Fax:315-702-8393
Practice Address - Street 1:37 W GARDEN ST
Practice Address - Street 2:SUITE 201
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021-2662
Practice Address - Country:US
Practice Address - Phone:315-567-0777
Practice Address - Fax:315-702-8393
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMF331895-1363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02639229Medicaid
NYS49878Medicare UPIN
NY34411LMedicare ID - Type Unspecified