Provider Demographics
NPI:1750644191
Name:SWANSON, JAY RICHARD (APRN-BC)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:RICHARD
Last Name:SWANSON
Suffix:
Gender:M
Credentials:APRN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WELLSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14895-1150
Mailing Address - Country:US
Mailing Address - Phone:585-595-1100
Mailing Address - Fax:
Practice Address - Street 1:191 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WELLSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14895-1150
Practice Address - Country:US
Practice Address - Phone:585-595-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-20
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF307721363LA2200X
NY715559163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse