Provider Demographics
NPI: | 1841242849 |
---|---|
Name: | YAWORSKI, SHAREN (NP) |
Entity Type: | Individual |
Prefix: | |
First Name: | SHAREN |
Middle Name: | |
Last Name: | YAWORSKI |
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: | 1575 WASHINGTON ST |
Mailing Address - Street 2: | |
Mailing Address - City: | WATERTOWN |
Mailing Address - State: | NY |
Mailing Address - Zip Code: | 13601-9371 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 315-786-7300 |
Mailing Address - Fax: | 315-786-7310 |
Practice Address - Street 1: | 1575 WASHINGTON ST |
Practice Address - Street 2: | |
Practice Address - City: | WATERTOWN |
Practice Address - State: | NY |
Practice Address - Zip Code: | 13601-9371 |
Practice Address - Country: | US |
Practice Address - Phone: | 315-786-7300 |
Practice Address - Fax: | 315-786-7310 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-05-17 |
Last Update Date: | 2011-05-02 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NY | F302428 | 363L00000X |
NY | F381457 | 363LP0200X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | |
No | 363LP0200X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NY | 00354316 | Medicaid | |
S67982 | Medicare UPIN |