Provider Demographics
NPI:1871647636
Name:CERVANTES, KRISTINE A (LPT)
Entity Type:Individual
Prefix:MRS
First Name:KRISTINE
Middle Name:A
Last Name:CERVANTES
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7960 JOSS FARM WAY
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:NY
Mailing Address - Zip Code:13039
Mailing Address - Country:US
Mailing Address - Phone:910-584-8571
Mailing Address - Fax:
Practice Address - Street 1:2949 ERIE BLVD E
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13224-1442
Practice Address - Country:US
Practice Address - Phone:315-251-1036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030277225100000X
NC9026225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC013X1OtherBCBS GROUP PROV. #
NC079FCOtherBCBS INDIV PROVIDER #
NC7211258OtherMEDICAID GROUP PROV. #
NC7211438Medicaid