Provider Demographics
NPI:1790985182
Name:HARGRAVE, GEORGIA ANN (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:GEORGIA
Middle Name:ANN
Last Name:HARGRAVE
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:GEORGIA
Other - Middle Name:ANN
Other - Last Name:BLACKBURN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:4 COMMERCE LANE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:NY
Mailing Address - Zip Code:13617
Mailing Address - Country:US
Mailing Address - Phone:315-393-9269
Mailing Address - Fax:315-393-3541
Practice Address - Street 1:4 COMMERCE LANE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617
Practice Address - Country:US
Practice Address - Phone:315-256-8191
Practice Address - Fax:315-386-1410
Is Sole Proprietor?:No
Enumeration Date:2007-07-23
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF332447363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03747862Medicaid
E07094Medicare UPIN
NY03747862Medicaid
NYG39318Medicare UPIN