Provider Demographics
NPI:1871507905
Name:RONALD, MICHAEL R (RN FNP, RNFA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:RONALD
Suffix:
Gender:M
Credentials:RN FNP, RNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 BRENTWOOD DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1865
Mailing Address - Country:US
Mailing Address - Phone:607-266-0073
Mailing Address - Fax:607-266-9310
Practice Address - Street 1:10 BRENTWOOD DR
Practice Address - Street 2:SUITE B
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1865
Practice Address - Country:US
Practice Address - Phone:607-266-0073
Practice Address - Fax:607-266-9310
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2008-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF331855363L00000X
NY331855207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02266791Medicaid
NYJ400000878Medicare PIN
NYP22267Medicare UPIN
NYRB3400Medicare PIN